LIBRARY OF CONGRESS. 



Chap, Copyright No, 

\ ^ Q h 



UNITED STATES QF AMERICA. 



A MANUAL 



OF 



CLINICAL DIAGNOSIS 

BY MEANS OF MICROSCOPIC AND 
CHEMICAL METHODS, 



FOR 



STUDENTS, HOSPITAL PHYSICIANS, AND PRACTITIONERS. 



BY 



CHARLES E. SIMON, M.D., 

LATE ASSISTANT RESIDENT PHYSICIAN, JOHNS HOPKINS HOSPITAL, BALTIMORE 
FELLOW OF THE AMERICAN ACADEMY OF MEDICINE. 



THIRD EDITION, THOROUGHLY REVISED. 
ILLUSTRATED WITH 136 ENGRAVINGS AND 18 PLATES IN COLORS 




LEA BROTHERS & CO. 

PHILADELPHIA AND NEW YORK 
1900 



a*\ 



£* 



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14091 

Library of Concrress 

Two Copies Received 
JUL 3 1900 

Copyright entry 

SECOND COPY. 

Delivered to 

ORDER DIVISION, 
JUL 18 1900 



65350 

Entered according to the Act of Congress in the year 1900, by 

LEA BKOTHEES & CO., 
In the Office of the Librarian of Congress. All rights reserved. 



HIS WIFE, 

WHO HAS SO FAITHFULLY AIDED IN ITS PREPARATION, 

THIS VOLUME IS AFFECTIONATELY DEDICATED 

BY THE 

AUTHOR. 



PREFACE TO THE THIRD EDITION. 



When, four years ago, I first placed my Clinical Diagnosis before 
the medical profession I pointed out that up to that time laboratory 
diagnosis had been greatly neglected, not only in this country, but 
also abroad. Even in our most modern medical institutions well 
equipped clinical laboratories could hardly be said to exist, and the 
subject, as such, was taught in none. Since that time great changes 
have taken place. Clinical laboratories are everywhere coming into 
existence, and are now regarded as being as important in medical 
education as the chemical and pathological laboratory, and special 
instructors have been appointed in many of our modern medical 
schools. 

The general practitioner has likewise appreciated the immense 
assistance offered him by modern methods of precision in diagnosis, 
and the obligation to utilize them for his patients' benefit. I am 
assured that a large part of the demand for this book has come from 
men in active practice, warranting the conclusion that my efforts 
to adapt it to their needs as well as to those of students have not 
miscarried. My purpose has been to state the best modern methods 
clearly and simply, with all necessary instructions, and to advance 
their utilization by rendering them practicable so far as possible with 
apparatus which every well-equipped physician should possess. 

In consequence of the growing interest in the subject a large num- 
ber of valuable contributions to its literature have appeared. The 
study of the blood especially has been widely taken up, and more 
detailed information than was given in my earlier editions has been de- 
manded and is now supplied. The entire work has been thoroughly 
revised, much new matter added, whole sections have been rewritten, 
methods rendered obsolete by the rapid advances of the science have 
been replaced by those representing the latest progress and new illus- 
trations added where necessary. Every effort, in short, has been 
made to render the book as modern and practical as possible. 



VI PREFACE TO THIRD EDITION. 

To many of my medical friends I am indebted for valuable sug- 
gestions, and I trust that this edition also will meet with the same 
favorable reception which was accorded the ones preceding. 

CHAELES E. SIMON. 

1302 Madison Avenue, 

Baltimore, Md., 1900. 



PREFACE TO THE SECOND EDITION. 



In the present edition the endeavor has been made to bring the 
volume thoroughly up to date. The parasitology and bacteriology of 
the blood, saliva, feces, urine, and vaginal discharge have been almost 
entirely rewritten. New methods of chemical examination which 
have appeared since the publication of the first edition have been 
embodied in the work, and some of the older and complicated ones 
omitted. Throughout the text numerous additions have been made, 
so that the size of the volume has been increased by about fifty 
pages. The examination of the cerebro-spinal fluid and its clinical 
significance have been carefully considered. Some of the illustra- 
tions have been replaced by more accurate ones, and others entirely 
new have been added where they appeared to be of value to the 
student. 

In conclusion, the writer wishes to thank the medical profession 
for the kind manner in which the first edition has been received. 

CHAELES E. SIMON. 

1302 Madison Avenue, 

Baltimore, Md., 1897. 



VI i 



PREFACE TO THE FIRST EDITION. 



It is curious to note that, notwithstanding the great importance 
of clinical chemistry and microscopy, but little attention is paid to 
these subjects, either by hospital physicians or by those engaged in 
general practice. This lack of interest is referable primarily to the 
fact that a systematic study of these branches has hitherto been 
greatly neglected, not only in American medical schools, but also in 
those of Europe. 

It is no rarity to hear physicians in general practice claim that 
they are too busy to conduct careful examinations of the urine, 
sputum, blood, gastric juice, etc. Would it not be reasonable to 
suppose, however, that a physician who is overwhelmed with work 
to such an extent that he cannot find the time to make use of aids 
in diagnosis which are quite as important as the stethoscope, the 
laryngoscope, or the ophthalmoscope, would be in a position to 
employ an assistant in his laboratory ? The younger practitioner is 
certainly not placed in such a dilemma, and it is a fair assumption 
that he could successfully compete with his more experienced col- 
league, in matters of diagnosis at least, were he to familiarize himself 
sufficiently with laboratory methods of diagnosis. 

The time is at hand when the practice of medicine is becoming 
what it was long ago, but then unjustly, called, a true science and 
art. No continuing success can be built on empiricism or upon the 
proportion of guesswork which is inseparable from dependence upon 
" the experienced eye." " Diagnosis " is now the password in med- 
ical science. A knowledge of electro-diagnosis, of ophthalmoscopy, 
of laryngoscopy, etc., is at the present day a sine qua non for accu- 
rate diagnosis. Equally important at all times, and frequently even 
more important, is a knowledge of clinical chemistry and microscopy. 
It is inconceivable that a physician can rationally diagnosticate and 
treat diseases of the stomach, intestines, kidneys, and liver, etc., 
without laboratory facilities. 

It has been the author's aim to present to students and physicians 



X PREFACE TO FIRST EDITION. 

those facts in clinical chemistry and microscopy which are of practi- 
cal importance. With the hope of exciting interest in these unjustly 
neglected subjects, he has not cou fined himself to bare statements of 
facts, which must in themselves be dry and uninteresting, but he 
has attempted to point out the reasons which have led up to the con- 
clusions reached. 

Chemical and microscopic methods are described in detail, so that 
the student and practitioner who has not had special training in such 
manipulations will be enabled to obtain satisfactory results. 

The subject-matter covers the examination of the blood, the secre- 
tions of the mouth, the gastric juice, feces, nasal secretion, sputum, 
urine, transudates, exudates, cystic contents, semen, vaginal dis- 
charges, and milk. In every case a description of normal material 
precedes the pathologic considerations, which latter in turn are fol- 
lowed by an account of the methods used in examination A glance 
■•at the table of contents will furnish an idea of the various subjects 
considered under each headiug. 

It was not deemed advisable to burden the volume with a com- 
plete enumeration of the various literary sources consulted by the 
author in its preparation, and the names of the various investigators 
mentioned in the text have been largely introduced as a matter of 
historical interest. 

In conclusion it is the agreeable duty of the author to express his 
sincerest thanks to his wife for assistance without which this volume 
could not have been written, and likewise for those illustrations 
which are original ; to Dr. William H. Welch for his kindness in 
placing the former Hygienic Laboratory of the Johus Hopkins 
Hospital at his disposal during the years 1892 and 1893; to Dr. 
W. Milton Lewis for much valuable aid in the correction of the 
manuscript and proof-sheets ; and to Messrs. Lea Brothers & Co. 
for the typographical excellence of the work, the extremely satisfac- 
tory reproduction of the drawings, and for many acts of courtesy. 

CHARLES E. SIMOX. 

Baltimore, Md., 1896. - 



CONTENTS. 



CHAPTEE I. 



THE BLOOD. 











PAGE 


General considerations . HH 17 


General characteristics of the blood . 








17 


color ........ 








17 


odor ........ 








18 


specific gravity ...... 








18 


determination according to Roy . 








18 


determination according to Hammerschlag 






19 


determination according to Schmaltz and Peiper 






19 


indirect estimation of the haemoglobin 






20 


estimation of the solids of the blood . 






20 


reaction ... ..... 






20 


estimation of the alkalinity according to Landois 


-v. J 


akscl 


l 21 


estimation of the alkalinity according to Lowy 






23 


Chemical examination of the blood .... 






24 


general chemistry of the blood .... 






24 


blood-pigments ....... 






28 


haemoglobin ...... 






28 


oxyhaemoglobin ...... 






28 


estimation of haemoglobin with Fleischl's haemonieter 


31 


estimation of haemoglobin with Gowers' haemoglobino 




meter ........ 


33 


estimation of blood-iron with Jolles' ferrometer 




. 34 


haemoglobinaemia 




38 


carbon monoxide haemoglobin 








. 39 


nitric oxide haemoglobin 








39 


sulphuretted hydrogen haemoglobin . 








39 


carbon dioxide haemoglobin 








40 


haematin ...... 








40 










40 


methaemoglobin ..... 








42 


haematoidin ..... 








42 


haematoporphyrin .... 








43 


the spectroscope ..... 








. 43 


the proteids of the blood .... 








. 45 


the carbohydrates ..... 








. 46 


sugar ....... 








46 


estimation of the sugar in the blood 








. 47 


Williamson's diabetic-blood (est . 








48 


glycogen 








48 


cellulose ...... 








49 



XI 



Xll 



CONTENTS. 



Chemical examination of the blood — Continued. 
urea ..... 

uraemia 
ammonia .... 

uric acid and xanthin bases 

fat and fatty acids 

lactic acid 

biliary constituents . 

acetone .... 

Microscopic examination of the blood 
the red corpuscles 

variations in the size of the red corpuscle 
variations in the form of the red corpuscles 
variations in the number of the red corpuscles 
variations in color ..... 

behavior towards anilin dyes 

granular degeneration .... 

nucleated red corpuscles .... 

the leucocytes ....... 

general differentiation of the various forms of leucocytes 

the anilin- stains . 

differentiation of the leucocytes according to their behavior 

toward anilin-stains 
variations in the number of the leucocytes 
leucocytosis ...... 

polynuclear neutrophilic hyperleucocytosis 
polynuclear eosinophilic hyperleucocytosis 
mixed hyperleucocytosis 
passive hyperleucocytosis (lymphocytosis) 
hypoleucocytosis (leukopenia) 
the drying and staining of blood 
Ehrlich's tri-acid stain 

staining with Ehrlich's hsematoxylin-eosin 
staining with Chenzinsky's eosin- methylene blue 
staining with Ehrlich's tri-glycerin mixture 
staining with Ehrlich's neutral mixture 
staining with eosin ..... 

basic double staining ..... 

staining with eosin -methylal and methylene blue 
special staining of basophilic leucocytes 
Neusser's stain ..... 

staining with Aronsohn and Philips' modified tri-acid stain 
Jenner's stain ..... 

Michael is' stain ..... 

distribution of the alkali in the blood . 
the plaques ...... 

the haBmokonia, or dust particles of Muller 

the enumeration of the corpuscles of the blood by the method of 

Thoma-Zeiss . . 

enumeration of the red corpuscles 
enumeration of the leucocytes . 
indirect enumeration of the leucocytes 
differential enumeration of the leucocytes 
enumeration of the plaques 
the hsematokrit ..... 



CONTENTS. 



xm 



Bacteriology and parasitology of the blood 
typhoid fever 

Widal's serum test 
pneumonia 
sepsis . 
anthrax 

acute miliary tuberculosis 
glanders 
influenza . 
relapsing fever . 
yellow fever 
malaria 
filariasis 
distomiasis 



PAGE 

100 
100 
100 
104 
105 
107 
107 
108 
108 
109 
110 
110 
119 
121 



CHAPTER II. 



THE SECRETIONS OF THE MOUTH. 



Saliva ....... 

general characteristics 
chemistry of the saliva 
microscopic examination of the saliva 
pathologic alterations 
the saliva in special diseases of the mouth 
catarrhal stomatitis 
ulcerative stomatitis . 
gonorrhoeal stomatitis . 
thrush . . . . 

Tartar ....... 

Coating of the tongue .... 

Tuberculosis of the mouth 
Actinomycosis ..... 

Coating of the tonsils .... 

pharyngomycosis leptothrica 
tonsillitis ...... 

diphtheria ..... 



122 
122 
122 
124 
126 
126 
126 
126 
127 
127 
127 
128 
128 
128 
129 
129 
129 
129 



CHAPTER III. 



THE GASTRIC JUICE AND THE GASTRIC CONTENTS. 



The secretion of the gastric juice 
Test-meals .... 

the test-breakfast of Ewald and 
the test-dinner of Riegel 
the double test-meal of Salzer 
the test-breakfast of Boas . 
The stomach-tube 

contraindications to the use of t 
the introduction of the tube 
General characteristics of the gastric 
Amount ..... 













132 












133 


Boas 










loo 
134 
134 
134 
134 


lie tube 










135 
186 


c juice 










137 
L88 



XIV 



CONTENTS. 



Chemical examination of the gastric juice 

chemical composition of the gastric juice . 
the acidity of the gastric juice .... 
determination of the acidity of the gastric juice 
the source of the hydrochloric acid . 
significance of the free hydrochloric acid . 
the amount of free hydrochloric acid 

euchlorhydria ...... 

hypochlorhydria ..... 

anachlorhydria ...... 

hyperchlorhydria ..... 

test for free acids ...... 

tests for free hydrochloric acid .... 

the dimethyl-amido-azo-benzol test 

the phloroglucin-vanillin test 

the resorcin test ...... 

the methyl-violet and emerald-green test . 

the tropseolin test ..... 

Mohr's test 

the benzopurpurin test .... 
the combined hydrochloric acid 
the quantitative estimation of hydrochloric acid 

Topfer's method . ... 

Martius and Luttke's method 

Leo's method ...... 

the ferments of the gastric juice and their zymogens 

pepsin and pepsinogen .... 
tests for pepsin and pepsinogen . 
quantitative estimation 

chymosin and chymosinogen 

tests for chymosin and chymosinogen . 
quantitative estimation 
the products of gastric digestion 

the digestion of native albumins 

the digestion of albuminoids 

the digestion of carbohydrates 
analysis of the products of albuminous digestion 
analysis of the products of carbohydrate digestion 
lactic acid ....... 

mode of formation and clinical significance 

tests for lactic acid ..... 

Uffelman's test ..... 

Kelling's test ..... 

Strauss' test ...... 

Boas' test ...... 

quantitative estimation of lactic acid according to 
method ....... 

the fatty acids . 

mode of formation and clinical significance 

tests for butyric acid ..... 

tests for acetic acid ..... 

quantitative estimation of the fatty acids . 

quantitative estimation of the organic acids 



Boas' 



139 
139 
139 
141 
143 
144 
146 
146 
146 
147 
147 
147 
148 
148 
149 
149 
150 
150 
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152 
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160 
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162 
162 
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162 
164 
164 
166 
167 
168 
168 
170 
170 
171 
171 
172 

173 
175 
175 
176 
177 
177 
177 
178 



CONTENTS. 



xv 



Chemical examination of the gastric juice — Continued 
acetone . . 
ptomains and toxalbumins 
vomited material 

food-material 

mucus 

gastrosuccorrhoea mucosa 

saliva .... 

bile .... 

pancreatic juice . 

blood .... 

test of Muller and Weber 

pus .... 

stercoraceous material 

parasites 

odor . . . . 
Microscopic examination of the gastric centents 
the Boas-Oppler bacillus 
sarcinse .... 
shreds of mucous membrane 
tumor particles . 
Examination of the motor power of the stomach 
Leube's method .... 
the salol test of Ewald and Sievers 
Examination of the resorptive power of the stomach 
Indirect examination of the gastric juice 
Giinzburg's method . 
the author's method . 



PAGE 

180 
180 
181 
181 
182 
182 
182 
183 
183 
183 
183 
184 
184 
184 
185 
185 
185 
186 
186 
187 
188 
188 
188 
189 
189 
189 
190 



CHAPTER IV. 



THE 


FECES 












Definition Wm .192 


Examination of the normal feces 














192 


general characteristics 














192 


number of stools . 














192 


amount 














192 


consistence and form . 














193 


odor .... 














193 


color .... 














193 


macroscopic constituents . 














193 


alimentary detritus 














193 


foreign bodies 














194 


microscopic constituents . 














194 


constituents derived from food 












194 


morphologic elements derived fro 


m th 


e alin 


lenta 


py cai 


ml 


195 


crystals .... 












196 


parasites 














L97 


vegetable parasites 














L97 


fungi 














197 


schizomycetes 














197 


bacteria 














198 


chemistry of normal feces . 














199 



XVI 



CONTENTS. 



Examination of the normal feces — Continued. 
reaction 

general composition . 
phenol, indol, and skatol 
fatty acids . 
cholesterin . 
the biliary acids . 
pigments 
Pathology of the feces 

general characteristics 
number of stools 
consistence and form . 
amount 

odor .... 
reaction 

color .... 
macroscopic constituents . 
alimentary constituents 
mucus and mucous cylinders 
biliary and intestinal concretions 
coproliths . 
analysis of gall-stones 
microscopic examination 
technique . 
remnants of food 
mucus 
epithelium . 
red blood-corpuscles 
leucocytes . 
crystals 
animal parasites 
protozoa 

amoeba coli 

cercomonas 

trichomonas 

megastoma entericum 

balantidium coli . 
vermes 

taenia saginata 

taenia solium 

taenia nana . 

taenia diminuta 

taenia cucumerina 

bothriocephalus latus 

krabbea grandis . 

distoma hepaticum 

distoma lanceolatum 

distoma Buskii 

distoma sibiricum 

distoma spatulatum 

ascaris lumbricoides 

ascaris mystax 

oxyuris vermicularis 

anchylostoma duodenale 

trichocephalus homiuis 



199 
199 
201 
203 
204 
205 
206 
206 
206 
206 
207 
207 
207 
208 
208 
210 
210 
211 
212 
213 
213 
213 
213 
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215 
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221 
222 
223 
223 
224 
225 
225 
226 
227 
227 
227 
229 
229 
229 
230 
230 
230 
231 
231 
232 
232 
233 



CONTENTS. 






xvii 


Pathology of the feces — Continued. page 


trichina spiralis ..... . 234 


anguillula intestinalis . 






. 234 


insecta ...... 






. 235 


vegetable parasites .... 






. 235 


bacillus of cholera 






. 235 


Finkler-Prior bacillus . 






. 236 


typhoid bacillus .... 






. 237 


tubercle bacillus .... 






. 239 


bacillus coli communis . 






. 239 


bacillus lactis aerogenes 






. 239 


bacillus pyocyaneus 






. 240 


proteus Hauser . . . . 






. 240 


chemistry of the feces .... 






. 241 


ptomains ....... 






. 242 


The feces in various diseases of the intestinal tract 






. 242 


acute intestinal catarrh .... 






. 242 


chronic intestinal catarrh ..... 






. 243 


cholera nostras ....... 






. 243 


summer diarrhoea of infants .... 






. 244 


dysentery ....... 






. 244 


amoebic dysentery ..... 






. 244 


cholera Asiatica ..... 






. 245 


typhoid fever ...... 






. 245 


Meconium ....... 






. 246 



CHAPTER V. 

THE NASAL SECRETION. 

The physiology and pathology of the nasal secretion 



247 



CHAPTER VI. 



THE SPUTUM. 



General technique 

General characteristics of the sputa 

amount 

consistence 

color . 

odor . 

specific gravity . 

configuration of sputum 
Macroscopic constituents of sputum 

elastic tissue 

fibrinous casts 

Curschmann's spirals . 

echinococcus membranes 

concretions 

foreign bodies 
Microscopic examination . 

leucocytes . 

red blood- corpuscles . 



249 
250 
250 
250 
251 
252 
252 
252 
253 
253 
253 
255 
257 



xvm CONTENTS. 

Microscopic examination — Continued. page 

epithelial cells .......... 258 

elastic tissue .......... 260 

animal parasites ...... ... 261 

taenia echinococcus ........ 261 

distoma pulmonale ........ 262 

vegetable parasites ......... 262 

pathogenic organisms ........ 262 

the tubercle bacillus ....... 262 

methods of staining ...... 265 

Pappenheim's method . . . . . 265 

Gabett's method 265 

Weigert-Ehrlich method 265 

Ziehl-Neelsen method 266 

the diplococcus pneumoniae ...... 266 

the bacillus of influenza ...... 267 

the bacillus of whooping-cough ..... 267 

actinomycosis . . . . . . . .268 

non-pathogeDic organisms ....... 268 

crystals . . 269 

Charcot-Leyden crystals ...... 269 

haematoidin ......... 269 

cholesterm ......... 269 

fatty-acid crystals ....... 270 

leucin and tyrosin ....... 270 

calcium oxalate ........ 270 

triple phosphates ....... 270 

Chemistry of the sputum ......... 270 

The sputa in various diseases ........ 271 

acute bronchitis . . . . . . . . .271 

chronic bronchitis ......... 271 

putrid bronchitis and pulmonary gangrene .... 272 

fibrinous bronchitis ......... 272 

bronchial asthma ......... 272 

pulmonary abscess ......... 272 

abscess of the liver with perforation into the lung . . . 272 

pneumonia .......... 273 

phthisis pulmonalis ......... 273 

oedema of the lungs ......... 274 

heart-disease . . . . . . . . . .274 

the pneumoconioses ......... 274 

anthracosis .......... 274 

siderosis . . . . . . . . . . 275 

chalicosis .......... 275 

stycosis .......... 275 

CHAPTER VII. 

THE URINE. 

General considerations ......... 276 

General characteristics of the urine ....... 277 

general appearance . . . . . . . . . 277 

color 278 

odor 279 



CONTENTS. 



xix 



General characteristics of the urine — Continued. 
consistence 
quantity 

polyuria 

oliguria 
specific gravity . 

determination of the specific gravity . 

determination of the solid constituents 
reaction ......... 

determination of the acidity of the urine 
The chemistry of the urine . 

general chemical composition of the urine . 
quantitative estimation of the mineral ash of the urine 
the chlorides ........ 

test for the chlorides in the urine 

quantitative estimation of the chlorides by the method of 
Salkowski-Volhard . 

direct method 

estimation of the chlorides after incineration according to 
Neubauer and Salkowski ..... 

the phosphates ......... 

test for the phosphates in the urine .... 

quantitative estimation of the total amount of phosphates 

separate estimation of the earthy and alkaline phosphates 

removal of the phosphates from the urine . 
the sulphates ........ 

tests for the sulphates in the urine 

quantitative estimation of the sulphates 

quantitative estimation of the total sulphates 
quantitative estimation of the conjugate sulphates 
the neutral sulphur . 

quantitative estimation 
urea ......... 

properties of urea . . . . . 

separation of urea from the urine 

quantitative estimation of urea . 

estimation of nitrogen according to Kjeldahl 

estimation of nitrogen according to Will-Varrent 
uric acid ........ 

properties of uric acid .... 

tests for uric acid ..... 

quantitative estimation of uric acid 
xanthin bases ....... 

quantitative estimation .... 
hippuric acid ....... 

properties of hippuric acid .... 

quantitative estimation of hippuric acid 
kreatin and kreatinin ..... 

properties of kreatin and kreatinin 

test for kreatinin in the urine 

quantitative estimation of kreatinin in the urine 
oxalic acid ....... 

properties of oxalic acid .... 

test for oxalic acid ..... 

quantitative estimation of oxalic acid . 



app 



279 
280 
281 
283 
283 
286 
287 
288 
292 
293 
293 
294 
295 
298 

298 
302 



303 
304 
308 
310 
312 
312 
313 
316 
317 
317 
318 
319 
321 
323 
329 
332 

ooo 
OOO 

341 
343 
345 
351 
352 
353 
359 
360 
361 
362 
363 
364 
365 

366 
367 
369 
370 
371 
371 



CONTENTS. 



The chemistry of the urine — Continued. 
the albumins .... 

serum -albumin . 

Patein's or aceto-soluble albumin 

serum-globulin . 

albumoses (peptones) . 

haemoglobin 

fibrin ..... 

nucleo-albumin . 

histon .... 

tests for the albumins 

tests for serum-albumin 
nitric-acid test 
boiling-test . 

potassium ferrocyanide test . 
trichloracetic-acid test 
picric-acid test 
Spiegler's test 

special test for serum-albumin 
quantitative estimation of albumin 
old method of boiling . 
volumetric method of Wassiliew 
Esbach's method . 
differential density method . 
gravimetric method 
test for serum-globulin and its quantitative estimation 
tests for albumoses 
tests for peptones 
tests for (mucin) nucleo-albumin 
tests for hsemoglobin 
Heller's test . 
the guaiacum test 
test for fibrin 
test for histon 
carbohydrates . 
glucose 

tests for sugar 

Trommer's test 

Fehling's test 

Bottger's test with Nylander's modification 

fermentation -test . 

phenyl-hydrazin test 

Kowarsky's modification 
polarimetric test . 
quantitative estimation of sugar . 
Fehling's method . 
Knapp's method . 
differential density method . . 
Einhorn's method . 
Lohnstein's method 
polarimetric method 
Bremer's diabetic-urine test . 
lactose ...... 

levulose . . . . ... 

maltose ...... 



CONTENTS. 



xxi 



The chemistry of the urine — Continued 
dextrin 
laiose . 
pentoses 
animal gum 
inosit . 
glycuronic acid 

urinary pigments and chromogens 
normal pigments 

urochrome .... 
uroerythrin . . . 

normal chromogens 

indican .... 

quantitative estimation . 
urohsematin .... 
uroroseinogen 
pathologic pigments and chromogens 
blood pigments 
hsematin 

urorubrohsematin and urofuscohsematin 
urohsematoporphyrin 
biliary pigments . 

Smith's test 
Huppert's test 



Gmelin's test, as modified by 



Gmelin's test . 
biliary acids . 
cholesterin 
pathologic urobilin 
melanin and melanogen 
phenol urines 
alkapton 

homogentisinic acid 
blue urines . 
green urines 

pigments referable to drugs 
Ehrlich's reaction 
conjugate sulphates . 

skatoxyl .... 
phenol and paracresol 
quantitative estimation 
pyrocatechin 
acetone 

tests for acetone . 
Legal' s test . 
Lieben's test 
Reynolds' test 
Dennige's test 
quantitative estimatioi 
diacetic acid 

Arnold's test 
oxybutyric acid . 
lactic acid . 
volatile fatty acids 
fat ... 



Rosenbach 



XX11 



CONTENTS. 



The chemistry of the urine — Continued. 
chyluria .... 
galaktosuria. 
ferments ..... 



gases ....... 

hydrothionuria .... 

ptomains ...... 

method of examination for ptomains 
Sediments ...... 

Microscopic examination of the urine 
non-organized sediments 

sediments occurring in acid urines 

uric acid .... 

amorphous urates 

calcium oxalate . 

ammonio-magnesium phosphate 

monocalcium phosphate 

neutral calcium phosphate . 

basic magnesium phosphate . 

hippuric acid 

calcium sulphate . 

cystin ..... 

leucin and tyrosir 

xanthin .... 

soaps of lime and magnesia . 

bilirubin and hgematoidin 

fat 

sediments occurring in alkaline urine 

basic phosphate of calcium and magnesium 

ammonium urate . 

magnesium phosphate . 

ammonio-magnesium phosphate 

calcium carbonate 

indigo ..... 
organized constituents of urinary sediments 
epithelial cells 
leucocytes .... 
red blood-corpuscles . 
tube-casts .... 

true casts . . 

hyaline casts 

waxy casts . 

pseudo- casts 

cylindroids .... 

formation of tube-casts 
clinical significance of tube casts 
spermatozoa 
parasites 

vegetable parasites 

animal parasites . 
tumor particles . 
foreign bodies 



CONTENTS. 



XXlll 



CHAPTER VIII. 



TRANSUDATES AND EXUDATES. 



Definition 
Transudates 

general characteristics 

specific gravity . 

chemistry of transudates 

microscopic examination 
Exudates .... 

serous exudates . 

hemorrhagic exudates 
tuberculosis 



cancer .... 

putrid exudates . . . 
pus . . . . ... 

general characteristics of pus 
the chemistry of pus . 
microscopic examination of pus 

leucocytes 

giant corpuscles . 

detritus 

red blood-corpuscles 

pathogenic vegetable parasites 

protozoa 

vermes . . . 

crystals 
chylous and chyloid exudates 



PAGE 

507 
507 
507 
507 
509 
509 
510 
510 
510 
510 
510 
511 
511 
511 
512 
512 
512 
513 
513 
514 
514 
514 
514 
514 
515 



CHAPTER IX. 

THE EXAMINATION OF CYSTIC CONTENTS. 



Cysts of the ovaries and their appendages 
Hydatid cysts ....•• 
Hydronephrosis . 

Pancreatic cysts . 



516 
518 
518 
518 



CHAPTER X. 



THE EXAMINATION OF CEREBKO-SPINAL FLUID. 



Definition . 

Amount 

Appearance 

Specific gravity 

Reaction . 

Chemical composition 

Microscopic examination 

Bacteriology 



519 
520 
520 
521 
522 



XXIV 



CONTENTS. 



CHAPTER XI. 

THE SEMEN. 

PAGE 

Definition .........••• 525 

General characteristics ......... 525 

The chemistry of the semen ........ 525 

The microscopic examination of the semen ..... 526 

The pathology of the semen ........ 526 

The recognition of semen in stains ....... 527 

CHAPTER XII. 

THE VAGINAL DISCHARGE. 

General description .......... 529 

Bacteriology ........... 529 

Vaginal blennorrhea ......... 530 

Menstruation ........... 531 

The lochia 531 

Vulvitis and vaginitis ......... 532 

Membranous dysmenorrhoea ........ 532 

Cancer ............ 534 

Gonorrhoea ........... 534 

Abortion ............ 534 



CHAPTER XIII. 



THE SECRETION OF THE MAMMARY GLANDS. 



The secretion of milk in the newly born 
Colostrum ..... 

The secretion of milk in the adult female 
Human milk ..... 
The milk in disease .... 

determination of the specific gravity 

the estimation of fat . 

the estimation of the proteids 



535 
535 
536 
536 
536 
538 
540 
540 



CLINICAL DIAGNOSIS. 



CHAPTER I. 
THE BLOOD. 

GENERAL CONSIDERATIONS. 

If blood is allowed to flow directly from an artery into a vessel 
surrounded by a freezing-mixture, and containing one-seventh of its 
own volume of a saturated solution of sodium sulphate, or a 25-per- 
cent, solution of magnesium sulphate (one volume to four volumes of 
blood), it will be observed that after some time a sediment, present- 
ing the ordinary color of arterial blood, has formed at the bottom, 
which is covered by a layer of clear, straw-colored fluid, the blood- 
plasma. 

Upon microscopic examination the sediment will be seen to con- 
tain : 

a. Numerous homogeneous, non-nucleated, circular, biconcave 
disks. These measure on an average 7.5 u in diameter, and are of a 
faint greenish-yellow color when viewed through the microscope, 
while en masse they present the color of arterial blood ; the erythro- 
cytes or red corpuscles of the blood. 

b. Roundish or irregularly shaped nucleated cells which are far 
less numerous than the red corpuscles, and devoid of coloring-matter ; 
the leucocytes, colorless or white corpuscles of the blood. 

c. Minute colorless disks, measuring less than one-half of the 
diameter of a red corpuscle ; the so-called plaques, or blood-plates of 
Bizzozero. 

GENERAL CHARACTERISTICS OF THE BLOOD. 

The Color. 

Chemical examination of the blood lias shown thai its color is 
referable to the presence of an albuminous, iron-containing substance, 
haemoglobin, in the bodies of the red corpuscles, which is characterized 
by its great avidity for oxygen, and forms a compound therewith, 
known as oxyhemoglobin. The relatively larger amount of the 
2 17 



18 THE BLOOD. 

latter encountered in the arteries, as compared with the veins, causes 
the difference in the appearance of arterial and venous blood, the 
former presenting a bright scarlet -red, the latter a dark-bluish color. 
A bright cherry-red color of the blood is noted in cases of poisoning 
with carbon monoxide, while a brownish-red or chocolate color is 
observed in cases of poisoning with potassium chlorate, aniline, hy- 
drocyanic acid, and nitrobenzol. A somewhat milky appearance is 
frequently seen in cases of well-marked leukaemia, and I recall an 
instance in which attention was first directed to the existence of this 
disease by the peculiarly milky appearance of a drop of blood 
obtained for the purpose of a haemoglobin estimation. In chlorosis 
and hydraemic conditions, as would be expected, the blood looks pale 
and watery. 

The Odor. 

The peculiar odor of the blood, which differs greatly in different 
animals, the halitus sanguinis of the ancients, is dependent upon the 
presence of certain volatile, fatty acids, and may be rendered more 
distinct by the addition of concentrated sulphuric acid. 

The Specific Gravity. 

The specific gravity of the blood in healthy adults varies between 
1.058 and 1.062 being higher on an average in men, 1.059, than in 
women, 1.056, and children — boys 1.052, girls 1.050. It is dimin- 
ished to a certain extent by fasting, the ingestion of solids and liquids, 
gentle exercise, pregnancy, etc. The specific gravity, moreover, de- 
pends upon the bloodvessel from which the specimen is taken, being 
higher, generally speaking, in venous than in arterial blood. 

Under pathologic conditions the specific gravity may vary between 
1.025 and 1.068. In nephritis, chlorosis, the anaemias in general, 
as also in cachectic conditions (pulmonary phthisis, carcinoma of the 
stomach, etc.), it may diminish to 1 .03 1 . An increased specific gravity 
is met with in febrile diseases (typhoid fever, 1.057 to 1.063), con- 
ditions associated with pronounced cyanosis (emphysema, fatty heart, 
uncompensated valvular disease, 1.054 to 1.068), and obstructive 
jaundice, 1.062. 

Methods of Determining the Specific Gravity of the 

Blood. 

Roy's Method. — A number of test-tubes are filled with a mixture 
of glycerine and water in different proportions, so that the specific 
gravity in the different tubes shall vary between 1.025 and 1.068. 
Blood is then drawn from the tip of a finger, or the lobe of the ear, 
into a capillary tube connected with an ordinary hypodermic syringe, 



GENERAL CHARACTERISTICS OF THE BLOOD. 19 

pressure being carefully avoided. A drop of blood is placed in each 
tube, in which it will sink as long as the specific gravity of the 
glycerine mixture is lower than that of the blood, while it will re- 
main suspended in a mixture the specific gravity of which is equiva- 
lent to its own. 

Eoy states that it is important for the purpose of comparison to 
make such examinations in every case at the same hour, as the spe- 
cific gravity of the blood has been shown to undergo diurnal varia- 
tions. 

Hammerschlag's Method. — A cylinder, measuring about 10 cm. in 
height, is partly filled with a mixture of chloroform (sp. gr. 1.526) 
and benzol (sp. gr. 0.889), presenting a specific gravity of 1.050 to 
1.060. Into this solution a drop of blood is allowed to fall di- 
rectly from the finger, pressure being avoided, and care being taken 
that it does not come in contact with the walls of the vessel. The 
drop, moreover, should not be too large, as it will otherwise separate 
into several droplets, giving rise to inaccurate results. Should the 
drop sink to the bottom, it is apparent that the specific gravity of 
the mixture is lower than that of the blood, necessitating the addi- 
tion of more chloroform. This should be added, drop by drop, 
while the mixture is thoroughly stirred. If, on the other hand, the 
drop should tend toward the surface, it is best to add an amount of 
benzol sufficient to cause the blood to sink to the bottom, and then to 
bring it to the proper degree of suspension by the subsequent addi- 
tion of chloroform. As soon as the drop remains suspended the 
mixture is filtered, and its specific gravity ascertained by means of an 
accurate areometer, registered to the fourth decimal. The figure ob- 
tained will express the specific gravity of the blood. 

The chloroform-benzol mixture may be kept indefinitely. 

With a little practice, results sufficiently accurate for clinical 
purposes may thus be obtained with an expenditure of but very lit- 
tle time. 

Schmaltz and Peiper's Method. — Where delicate scales are avail- 
able the method of Schmaltz and Peiper may be employed, and is 
certainly the most accurate : A capillary tube, measuring about 1 2 
cm. in length and 1.5 mm. in width, with its ends tapering to a 
diameter of 0.75 mm., is filled with blood and carefully weighed, 
when the weight of the blood, divided by the weight of an equivalent 
volume of distilled water, will indicate the specific gravity. 

As the result of numerous investigations it may now be regarded 
as an established fact that with the exception of nephritis, circulatory 
disturbances, leukaemia, and possibly also post-hemorrhagic anaemia 
and that resulting from inanition, the specific gravity of the blood 
varies directly with the amount of haemoglobin. A simple method is 
thus given by means of which haemoglobin estimations can usually be 



20 



THE BLOOD. 



made in the absence of more expensive instruments. In the follow- 
ing tables the varying degrees of specific gravity, as obtained with 
Hammerschlag's method, and that of Schmaltz and Peiper, are given 
with the corresponding amounts of haemoglobin. The figures, how- 
ever, are in all probability not quite accurate : 



Specific gravity 






Specific gravity 






according to* 


Hcemoglobin. 


according to 
Schmaltz and Peiper. 


Haemoglobin 


Hammerschlag. 










1.033-1.035 


. 25-30 


per ct. 


1.030 . 


. 20 per ct. 


1.035-1.038 


. 30-35 


u 


1.035 . 


. 30 


" 


1.038-1.040 


. 35-40 


a 


1.038 . 


. 35 


n 


1.040-1.045 


. 40-45 


" 


1.041 . 


. 40 


" 


1.045-1.048 


. 45-55 


« i 


1.0425 . 


. 45 


" 


1.048-1.050 


. 55-65 


a 


1.0455 . 


. 50 


" 


1.050-1.053 


. 65-70 


" 


1.048 . 


. 55 


" 


1.053-1.055 


. 70-75 


" 


1.049 . 


. 60 


" 


1.055-1.057 


. 75-85 


" 


1.051 . 


. 65 


a 


1.057-1.060 


. 85-95 


i ( 


1.052 . 
1.0535 . 
1.056 . 
1.0575 . 


. 70 

75 

. 80 

. 90 


a 
a 








1.059 . 


. 100 


it 



Direct Estimation of the Solids of the Blood. 

A few drops of blood (0.2 to 0.3 gramme), obtained by means of 
a fairly deep incision, or puncture, into the tip of a finger, moderate 
pressure being made upon the middle phalanx, if necessary, are col- 
lected in a watch-crystal. This is at once covered with its fellow 
and weighed. The specimen (open) is then dried at a temperature 
of from 60° to 70° C. for twenty-four hours, and again weighed, the 
weight of the solids being thus ascertained. 

In healthy adults the following values were obtained by Stintzing 
and Gumprecht : 



In men 
In women 



Average. 
21.6 
19.8 



Maximum. 
23.1 
21.5 



Minimum. 

19.6 

18.4 



Average water. 
78.4 per cent. 
80.2 " 



In conditions associated with chronic anaemia the solids, as would 
be expected, are always much diminished. In leukaemia, on the 
other hand, owing to the large number of leucocytes present, a rela- 
tive increase is observed. 



The Reaction. 

The reaction of the blood during life, owing to the presence of 
disodium phosphate and sodium carbonate, is alkaline, the degree of 
alkalinity in terms of sodium hydrate under normal conditions corre- 
sponding to 182 to 218 mgrms. for every 100 c.c. of blood, v. 
Jaksch gives 260 to 300 mgrms. as the normal, and Canard 203 to 
276 mgrms. 



GENERAL CHARACTERISTICS OF THE BLOOD. 21 

The alkaline reaction of the blood may be demonstrated by re- 
peatedly drawing a strip of red litmus-paper, thoroughly moist- 
ened with a concentrated solution of common salt, through the 
blood, and rapidly washing off the corpuscles with the same solu- 
tion, when, as a general rule, the alkaline reaction can be clearly 
made out. 

Small plates of plaster-of-Paris or clay, stained with neutral 
litmus-solution, may be similarly employed, the blood in this case 
being washed off with water. 

Generally speaking, the alkalinity of the blood is lower in women 
and children than in men, and is, furthermore, influenced by the 
process of digestion, exercise, etc. At the beginning of digestion, 
when hydrochloric acid is being secreted in large amounts, the 
alkalinity of the blood increases, while later on, when both hy- 
drochloric acid and peptones are reabsorbed, the alkalinity in turn 
diminishes. 

A decrease is observed following violent muscular exercise, such 
as forced marches in the case of soldiers, owing, in all probability to 
an excessive production of acids in the muscles. 

Under pathologic conditions a diminished alkalinity of the blood 
is frequently observed. This is particularly marked in cases of se- 
vere anaemia (108 to 145 mgrms. of NaOH), and increases as the 
number of red corpuscles and the amount of haemoglobin diminish. 
In chlorosis, however, the diminution in the number of red corpus- 
cles is accompanied by a normal, or but slightly diminished alkalin- 
ity of the blood as a whole. In leukaemia, pernicious anaemia, ne- 
phritis, when accompanied by uraemia, various hepatic diseases, 
diabetes, carcinoma, the various profound cachexiae, pseudo-leukaemia, 
poisoning with carbon monoxide, and acids, and finally in high fever, 
as in typhoid fever, and toxic processes in general, the alkalinity of 
the blood is diminished, the lowest value found corresponding to 108 
mgrms. of NaOH. A similar decrease follows the prolonged use of 
acids, while an increase is brought about by the ingestion of alkalies. 
An increase in the alkalinity of the blood occurs after a cold bath, 
and it is interesting to note that this is apparently associated with an 
increase in the bactericidal power of the blood. Possibly the bene- 
ficial effect of the cold baths in fever may be explained upon this 
basis. The supposition that in gout a diminished alkalinity exists 
between the attacks, and that this increases beyond the normal dur- 
ing the attack, has been proven incorrect. 

v. Jaksch employs the following method, a modification oi' that 
originally devised by Landois : Eighteen watch-crystals are pre- 
pared, each containing a mixture of a concentrated solution o( so- 
dium sulphate and a t -Jq- and a --^/j,, normal solution of tartaric 
acid, in varying proportions, so that crystal 



22 THE BLOOD. 

No. C.c. C.c. 

I. Shall contain 0.9 of the ^ norm. sol. of the acid, and 0.1 of the cone. Nai'SCh sol. 

II. " " 0.8 " " " " " " 0.2 " 

HI. « " 0.7 " " " " " " 0.3 " 

IV. " " 0.6 " " " " " " 0.4 " 

V. " " 0.5 " " " " " " 0.5 " 

VI. " " 0.4 " " " " " " 0.6 " 

VII. " " 0.3 " " " " " " 0.7 " 

VIII. " " 0.2 " " " " " " 0.8 " 

IX. " " 0.1 " " " " " " 0.9 " 

x. " " o.9 «; t A(t ;; ;; ;; ;; o.i ;; 

XI. " " 0.8 " " . " " " " 0.2 " 

etc., for every c.c. of the mixture. 

Blood is taken, preferably from the back, by means of cupping- 
glasses, and, before it coagulates, 0.1 c.c, is added to every c.c. of 
the mixture described, when the reaction is determined in every 
crystal by means of very sensitive litmus-paper. The amount of 
acid contained in the specimen exhibiting a neutral reaction in terms 
of XaOH will then indicate the degree of alkalinity of the blood. 

As 150 (molecular weight) parts by weight of tartaric acid 
(C 4 H fi O g ) combine with 80 (molecular weight) parts by weight of 
NaOH, or 75 with 40, according to the equation : 

COOH COOXa 

C 2 H 2 (OH) 2 < + 2XaOH = C 2 H,(OH) 2 < + 2H 2 

COOH COONa 

a normal solution would contain 75 grammes of pure tartaric acid to 
the litre and a T -J 7 and a y-oVo normal solution, respectively, 0.75 
and 0.075 gramme. As 1,000 c.c. of a y-J-g- normal solution would 
correspond to 0.4 gramme of NaOH, and 1,000 c.c. of a j-^q-q normal 
solution to 0.04 gramme, 1 c.c, of the yj^ normal solution will 
represent 0.0004, and 1 c.c. of the y^ -^ normal solution 0.00004 
gramme of NaOH. 

Supposing, then, that a neutral reaction was obtained in the crystal 
containing 0.6 c.c. of the yj-g- normal solution, the alkalinity of the 
0.1 c.c. of blood in terms of XaOH would correspond to 0.00024 
gramme of NaOH, or 0.24 gramme for 100 c.c. of blood. 

As the alkalinity of the blood rapidly diminishes after being 
drawn, owing, in all probability, to the formation of an acid caused 
by the decomposition of the haemoglobin, it is apparent that the ex- 
periment must be performed as rapidly as possible, and not more 
than one minute and a half should elapse between the taking of the 
blood and the conclusion of the experiment, 

This method has hitherto been the only one which was available 
for clinical purposes, and the results detailed above have been 
obtained by its aid. It is open to numerous objections, however, 
and still too complicated for routine work. Of late a new method, 
suggested by Lowy, has attracted much attention, and, to judge from 
the literature before us, is destined soon to replace the one described. 



GENERAL CHARACTERISTICS OF THE BLOOD. 23 

It is both simpler and more accurate. The results, however, differ 
considerably from those given above, and a careful revision of all the 
work thus far accomplished with the old method will be necessary 
before definite conclusions can be reached. For the convenience of 
future investigators a table is here appended containing some of the 
results Avhich have already been obtained in some of the more im- 
portant diseases. In healthy adults, while fasting, the alkalinity of 
the blood, according to Lowy, corresponds to about 300 to 325 mgrms. 
of sodium hydrate for every 100 c.c. of blood. Variations, amount- 
ing to 75 mgrms., plus or minus, are, however, not uncommon, and, 
according to Strauss, the unavoidable errors may correspond to 30 
mgrms. : 

Carcinoma oesophagi . . . . . . 227-643 

Carcinoma ventriculi ....... 256-635 

Ulcus ventriculi 302-460 

Anadeny of the stomach ...... 354-360 

Alcoholic gastritis ....... 343-379 

Chronic enteritis 212-272 

Phthisis pulmonalis ....... 450-468 

Bronchitis 239-343 

Neurasthenia 225-426 

Arterio-sclerosis 208-344 

Chronic arthritis 368-465 

Erysipelas 498 

Typhoid fever 270-640 

Pneumonia 263-464 

Septicaemia ......... 443 

Leukemia 368-835 

Pernicious anaemia ....... 429 

Diabetes mellitus . . 362-457 

Chronic interstitial nephritis 310-409 

Chronic parenchymatous nephritis .... 312-490 

Cirrhosis of the liver ....... 272-345 

Lowy's Method. — Five c.c. of blood, obtained from one of the 
superficial veins of the arm (preferably the median cephalic), are 
allowed to flow into a small flask provided with a long and partially 
graduated neck and containing 45 c.c. of a 0.25-per-cent. solution 
of ammonium oxalate. Coagulation is thus prevented and the blood 
made lake-colored — i. e., the haemoglobin is dissolved from the 
stroma of the red corpuscles. The mixture is then titrated with a 
■fe normal solution of tartaric acid using lacmoid paper, soaked in a 
concentrated solution of magnesium sulphate, as an indicator. The 
lacmoid paper is prepared as follows : 

A mixture of 100 grammes of resorcin, 5 grammes of sodium 
nitrite, and 5 c.c. of distilled water is heated on an oil bath to a 
temperature of 110° C. A violent reaction occurs at this point, and 
the flame should be removed before it is reached. The substance 
is then heated to a temperature of 1 L5°— 120° (\, until all the am- 
monia which is evolved during the process has been driven off. The 



24 THE BLOOD. 

residue, which should be of a pure blue color, is dissolved in water 
and precipitated with hydrochloric acid. On cooling, the coloring- 
matter is filtered off with the aid of a suction-pump, and washed 
with a little water. It is then dissolved in absolute alcohol, filtered, 
and the solution allowed to evaporate in an atmosphere free from 
ammonia. One gramme of the pigment, which crystallizes out in 
reddish-brown, glistening platelets, is dissolved in 1,000 c.c. of 45- 
per-cent. alcohol, when strips of fine Swedish filter-paper are soaked 
in the solution and allowed to dry. 

As a normal solution of tartaric acid contains 75 grammes to the 
litre (see page 22), a ^ normal solution will contain 3 grammes, 
and 1 c.c. of the -^ normal solution will correspond to 0.0016 
gramme of sodium hydrate. 

Supposing, then, that 10 c.c. of the ^V normal solution were 
necessary to neutralize the 5 c.c. of blood, the alkalinity of these 5 
c.c. in terms of sodium hydrate would correspond to 0.016 gramme, 
and the alkalinity of 100 c.c. of blood to 0.016 x 20 = 0.320 gramme 
— i. e., to 320 mgrms. 

CHEMICAL EXAMINATION OF THE BLOOD. 

General Chemistry of the Blood. 

A general idea of the chemical composition of the blood may be 
formed from the accompanying table of C. Schmidt, calculated for 
1000 parts : 

Corpuscles ...... 

Water 

Haemoglobin and globulins . 

Mineral salts .... 

Plasma ...... 

Water ...... 

Fibrin ...... 

Albumins and extractives 

Mineral salts .... 

If blood is allowed to flow into a vessel and set aside, it will be 
observed that at the expiration of a few minutes the entire mass has* 
become transformed into a semi-solid, gelatinous material, which is 
spoken of as the blood-clot or the placenta sanguinis. Still later it 
will be seen that a small amount of straw-colored fluid has appeared 
on top of the clot, which gradually increases in amount, while the 
clot itself undergoes shrinkage, until finally it floats, greatly dimin- 
ished in size, in the surrounding fluid. The straw-colored fluid 
which has thus been obtained during the process of coagulation is 
spoken of as the blood-serum. 

1 This figure is too high ; in man it varies between 420 and 470 for 1,000 parts of 
blood. 



Man. 


Woman. 


. 513.0 1 


369.2 


. 349.7 


272.6 


. 159.6 


120.1 


3.7 


3.55 


. 486.9 


603.8 


. 439.0 


552.0 


3.9 


1.91 


. 39.9 


44.79 


4.14 


5.07 



CHEMICAL EXAMINATION OF THE BLOOD. 25 

If a bit of the clot is examined microscopically it will be seen to 
consist of a more or less dense network of fibres, the meshes of which 
are filled with blood-corpuscles, which may be washed out, leaving 
the fibrous network, fibrin behind. 

Chemically speaking, fibrin belongs to the class of the so-called 
coagulated albumins, and probably does not occur in the circulating 
blood, but is formed only during the process of coagulation. 

The albumins which are found in the plasma are fibrinogen, serum- 
globulin, and serum-albumin, but while the last two are likewise 
encountered in the serum, the fibrinogen has disappeared, and traces 
of a new albuminous body, fibrino-globulin, are found. There ap- 
pears to be no doubt that fibrin results from the fibrinogen by a proc- 
ess of dissociation, and that the traces of fibrino-globulin are formed 
at that time. Modern research, furthermore, has shown that the 
transformation of fibrinogen into fibrin is dependent upon the action 
of a special ferment, the fibrin-ferment, which is derived in all 
probability from the leucocytes of the blood, by a process of plasmo- 
schisis. The presence of serum-globulin apparently hastens coagu- 
lation in an indirect manner, as is done by calcium chloride and the 
calcium salts in general. 

Under normal conditions blood clots in from two to six minutes 
after being shed, while in disease, notably in haemophilia, coagulation 
may be greatly retarded or does not occur at all, so that fatal hemor- 
rhage may follow the infliction of trifling wounds. Whether or not 
this condition is referable to certain abnormalities in the chemical 
composition of the blood is as yet undetermined. 

A tendency to hemorrhage is also observed in scurvy, purpura, in 
some infectious diseases, such as typhoid fever, yellow fever, in 
poisoning with phosphorus, etc. Sicard has recently pointed out 
that in purpura, primary coagulation occurs as with normal blood, 
but that subsequent retraction of the clot and exudation of serum only 
takes place to a very limited extent. Normal sera, when added to 
such fluids, as hydrocele fluid, which are not spontaneously coagulable, 
in the proportion of 1 : 80, induce coagulation in from four to six 
hours. The serum of purpuric patients, on the other hand, is either 
entirely devoid of this property, or possesses it only to a very slight 
degree. The addition of a trace of calcium chloride, however, causes 
such serum to behave very much like normal serum. Sicard hence 
suggests that in certain cases of purpura the fibrin ferment, or its pro- 
enzyme is not present in sufficient quantity to cause more than a 
primary coagulation. Subsequent retraction, however, may also be 
due to the action of another variety of fibrin the zymogen of which 
is absent in purpura. 

Since the formation of fibrin begins as soon as the blood has left 
its natural channels, it is apparent that absolutely accurate analyses 



26 THE BLOOD. 

of blood-plasma can hardly be expected. The appended analyses of 
the plasma of the horse's blood are taken from Hoppe-Seyler and 
Hammarsten, the figures having reference to 1000 parts : 

Water 908.4 917.6 

Solids 91.6 82.4 

Total albumins 77.6 69.5 

Fibrin 10.1 6.5 

Globulin 38.4 

Serum-albumin . . . . . 26.4 

Fat 1.2 1 

Extractives . 4.0 I 

Soluble salts 6.4 [ 

Insoluble salts . . . . . .1.7 



12.! 



The chief points of difference between plasma and serum are the 
absence of fibrinogen and the presence of traces of fibrino-globulin, as 
well as of large quantities of fibrin-ferment, in the latter. 

From the following table it will be seen that a marked difference 
exists in the nature of the mineral ingredients between serum and 
the red corpuscles, the latter being relatively rich in potassium salts 
and phosphorus, and poor in sodium salts and chlorine. 

The figures have reference to 1,000 parts of blood : 

Man. Woman. 





Red 




Red 






corpuscles. 


Serum. 


corpuscles. 


Serum. 


K 2 . 


. 1.586 


0.153 


1.412 


0.200 


Na.,0 . 


. 0.241 


1.661 


0.648 


1.916 


CaO . 










MgO . 










Fe 2 5 . 










CI 


. 0.898 


1.722 


0.362 


1.44 


PA • 


. 0.695 


0.071 


0.643 


2.202 



It is noteworthy that the amount of sodium chloride in the serum, 
6 to 7 p. m., remains fairly constant, no matter whether large 
amounts are ingested or none are given at all. It is quite 
probable that the sodium chloride of the plasma serves the pur- 
pose of preventing the haemoglobin of the corpuscles from being 
dissolved by the water of the blood. The term " isotonic" has 
been applied, by Hamburger to a salt solution which is just strong 
enough to prevent the solvent action of the water upon the haemo- 
globin of the red corpuscles. In the case of the serum, however, 
we meet with a condition of hyperisotonia — i. e., an amount of salt 
in excess of that actually required in order to prevent the destruc- 
tion of the red corpuscles, the advantage of which is, of course, 
apparent, if the variations, to which the amount of water in the 
blood is subject, are borne in mind. 

In addition to the substances mentioned, the following are also 
found in the blood : 



CHEMICAL EXAMINATION OF THE BLOOD. 27 

Fat occurs in amounts varying from 1 to 7 p. m. in fasting 
animals, while following the ingestion of a meal rich in fats as much 
as 12.5 p. m. have been encountered. 

Soaps, cholesterin, and lecithin have likewise been found. 

Sugar, probably glucose, appears to form a normal constituent of 
the plasma, amounting to from 1 to 1.5 p. m. in man. While it is 
possible to increase this amount to a certain degree by the ingestion 
of large quantities of sugar, this appears in the urine, according to 
Claude Bernard, as soon as 3 p. m. has been exceeded. In addition 
to glucose another reducing-substance has been found in the blood, 
which differs from the former in not being fermentable. 

Among the extractives which have been found there may be 
mentioned : urea, uric acid, kreatin, carbamic acid, sarco-lactic acid, 
glycogen, and hippuric acid, and under pathologic conditions xanthin, 
hypoxanthin, paraxanthin, adenin, guanin, leucin, tyrosin, lactic acid, 
cellulose, /3-oxybutyric acid, acetone, and biliary constituents. 

It has been pointed out that the color of the blood is referable to 
the presence of haemoglobin in the red corpuscles, and that it varies 
from a bright scarlet-red in the arteries to a dark bluish-red in the 
veins, the exact shade depending upon the amount of oxygen present 
in combination with haemoglobin as oxyhemoglobin. Upon chemical 
examination two other gases may be demonstrated under physiologic 
conditions, viz, carbon dioxide and nitrogen. Of these the latter 
appears to play no part in the body-economy, and the amount present 
merely corresponds to that which would be absorbed by an equal 
volume of distilled water, viz, 1.8 vol. p. c, calculated at 0° C. and 
760 Hgmm. pressure. 

The amount of oxygen and carbon dioxide, on the other hand, 
undergoes considerable variation, depending upon the particular 
bloodvessel from which the specimen is taken — i. e., whether this be 
an artery or a vein, and, furthermore, upon the velocity of the blood- 
current, the temperature of the body, rest, exercise, etc. 

The relation existing between the amounts of these gases in arteries 
and veins may be seen from the following table : 





Arterial blood. 


Venous blood. 


Oxygen 

Carbon dioxide . 


21.6 per cent. 
. 40.3 " 


6.8 per cent. 
48.0 " 


Nitrogen 


1.8 " 


1.8 " 



Oxygen, as already pointed out, occurs principally in chemical 
combination with haemoglobin (oxy haemoglobin), only 0.26 per cent. 
being present in solution in the plasma. 

Of the carbon dioxide which may be obtained from the blood, 
only one-tenth is held in solution, while the remaining portion is 
found in the red corpuscles, in the form of a Loose compound with 



28 



THE BLOOD. 



the alkalies of the corpuscles, and possibly also in combination with 
haemoglobin. This portion amounts to about one-third of the total 
quantity, while the remaining two-thirds are probably held in chem- 
ical combination by the alkalies of the plasma and certain albuminous 
bodies. 

Blood-pigments. 

Hsemoglobin. — Haemoglobin as such is only found in relatively 
small amounts in the circulating blood, occurring essentially in com- 
bination with oxygen as oxyhemoglobin, which predominates in 
arterial blood, while a mixture of oxyhemoglobin and haemoglobin 
is met with in venous blood, and haemoglobin is present almost ex- 
clusively in the blood of asphyxia. 

The spectrum of haemoglobin, in suitable dilution, shows a single 
band of absorption between D and E, which, however, does not lie 
midway between these lines, but extends slightly beyond D to the 
left (Fig. 1). The substance is characterized by the ease with which 
it forms compounds with certain gases, and notably so with oxygen. 




Spectrum, of reduced haemoglobin, (v. Jaksch.) 

As has been stated above, carbon dioxide, to a certain extent at 
least, also occurs in combination with haemoglobin. In cases of 
poisoning compounds of haemoglobin with carbon monoxide, with 
nitric oxide, and possibly also with sulphuretted hydrogen, cyanogen, 
and acetylene have been observed. 

Oxy haemoglobin. — Oxyhemoglobin is the most important con- 
stituent of the blood. In sufficiently dilute solution it shows two 
bands of absorption between D and E ; one band, a, which is not 
so wide as the second, /9, but darker and more sharply denned, bor- 
ders on JD, while the second, which is wider, but less sharply denned, 
lies at E (Fig. 2). This spectrum can be readily transformed into 
that of haemoglobin by the addition of a reducing agent, such as an 
ammoniacal solution of ferrous tartrate (Stokes' fluid), ammonium 
sulphide, or cuprous salts. 

Under normal conditions the amount of oxyhaemoglobin is fairly 
constant, but varies somewhat in different countries, in accordance 
with the habits of the people. As a result of sixty-one estimations 



CHEMICAL EXAMINATION OF THE BLOOD. 



29 



Leichtenstern found 14.16 per cent, as the average in healthy men, 
13.10 per cent, in women, and in old age about 95 to 115 per cent, 
of the normal. Among the inhabitants of the large cities of our 
country such excellent results are only exceptionally obtained, and, 
in my experience it is rare to find more than 13.01 per cent. As a 
general rule amounts varying between 10.96 and 12.33 per cent, are 
observed. This diiference is undoubtedly owing to the fact that the 
average German spends very much more of his time outside the city- 
limits than the average American. Larger amounts are thus also 
found among the French and the English. 

While the ingestion of large amounts of water does not call forth 
a dilution of the blood and a diminution in the amount of oxyhe- 
moglobin, an increase occurs upon the withdrawal of liquids. Fat 
persons show a smaller amount of oxyhemoglobin than corresponds 
to their age. 

A great diminution in the amount of oxyhemoglobin may be 
encountered under pathologic conditions, and especially in chlorosis, 
while a relative increase is not infrequently met with in diabetes 



Fm. 2. 



Yellow 




Green 



Cyan-blue 



Eb F 

80 90 100 110 

ll I I I I 1 I I I I III I l.lll I I I II I I ll I 



Spectrum of oxyhemoglobin, (v. Jaksch.) 

mellitus, owing to the excretion of abnormally largejquantities of 
water. In nephritis with pronounced oedema it falls considerably 
below the normal. &>*SQ J2H 

In a series of observations Quincke found the following amounts 
in the diseases indicated : 









Fleischl. 1 


Angina pectoris . 


14.4 per cent. 


107.0 


Cerebral apoplexy 


. 14.1 


" 


104.9 


Scurvy 


. 14.6 


" 


108.6 


Hepatic cirrhosis . 


. 10.1 


(< 


75. 1 


Chlorosis 


. 5.32-9.92 


c< 


39.5-73.9 


Splenic leukaemia 


. 5.8 


(< 


48. 1 


Nephritis 


. 8.5-10.7 


a 


68.2-70.6 


Diabetes 


. 14.4-15.D 


a 


107. 1-1 is.:; 


Typhoid fever 


. 12.7-14.6 


it 


94. 4-1 OS. li 


Recurrens . 


. 14.4 


a 


107.0 


Meningitis . 


. 15.0 


a 


111.6 


Pyaemia 


. 11.3 


a 


84.0 


Phosphorus-poisoning 


. 14.9 


a 


110.8 


1 Sec estimation of hse 


noglobin with Fleisc 


Id's hsem< 


uneter. p. 32. 



30 THE BLOOD. 

In an analysis of 63 cases of chlorosis, observed at the Johns 
Hopkins Hospital, an average amount of 5.68 per cent. (42.3, 
Fleischl), with a minimum of 2.35 per cent. (17.5), was observed. 
Similar results were obtained by the writer in an analysis of 31 
cases. The average amount Avas 6.46 per cent. (42.8, Fleischl), 
and the lowest 2.46 per cent. (18, Fleischl). Chlorosis thus occu- 
pies the foremost position among the various pathologic conditions 
associated with oligochromemia. 

Very low figures are also seen in cases of pernicious anaemia and 
leukaemia, where 2.68 per cent. (20, Fleischl) and 4.36 per cent. 
(32.5), respectively, have been obtained. 

While in typhoid fever the amount of oxyhemoglobin is always 
reduced, according to Osier, and usually in a greater relative pro- 
portion than the number of the red corpuscles, the most severe 
grades of anaemia may here be encountered during convalescence, 
when the amount of oxy haemoglobin may fall as low as 2.68 per 
cent. (20, Fleischl). 

In the early stages of carcinoma of the stomach the cachexia is 
not well pronounced, and Schtile states that in his analysis of 198 
cases it only occurred in 30 per cent. This agrees entirely with 
my experience, and I have repeatedly found amounts of haemoglobin 
exceeding 60 per cent. Later in the disease a most pronounced 
oligochromemia is, however, invariably encountered. At this place 
I wish to insist upon the importance of systematically repeated ex- 
aminations of the blood in all cases of suspected carcinoma of the 
stomach. A steady decline from week to week, when taken in con- 
junction with other symptoms, and occurring in patients who have 
passed the fourth decade, is certainly very suspicious. 

A notable diminution in the amount of haemoglobin is further 
observed in tuberculosis, syphilis, chronic lead and mercurial poison- 
ing, chronic nephritis, chronic enteritis, etc. 

As the oxyhemoglobin is contained in the bodies of the red cor- 
puscles, it might be inferred that the amount of haemoglobin will 
directly depend upon the number of the corpuscles, so that the degree 
of an anaemia could be determined by an enumeration of the red cor- 
puscles as well as by a direct estimation of the amount of oxyhemo- 
globin. 

While this rule generally holds good, there are numerous excep- 
tions which go to show that a diminution in the amount of oxyhe- 
moglobin, viz, an oligochromasia, is not necessarily accompanied by 
a corresponding diminution in the number of the red corpuscles — 
i. e.j an oligocythemia. In chlorosis, for example, the red corpuscles 
may be present in normal numbers, while the amount of oxyhemo- 
globin is greatly diminished. Here, it is true, a well-defined oligo- 
cythemia simultaneously occurs in all severe cases, but even then 






CHEMICAL EXAMINATION OF THE BLOOD. 31 

the oligochromaemia exceeds the oligocythemia. Conversely, in 
pernicious anaemia the oligocythemia, while accompanied by an 
oligochromaemia, quite constantly exceeds the latter. 

It is thus clear that definite inferences regarding the amount of 
haemoglobin cannot be drawn from an enumeration of the red cor- 
puscles, and vice versa. 

While it is generally possible to form a fairly clear idea of the 
degree of anaemia by inspection — i. e., by noting the "color" of 
the patient — it is a well-known fact that not every pale face denotes 
an anaemic condition. "Whenever special accuracy in examination or 
results for comparison are desired, recourse should hence be had to 
instruments especially devised for the purpose of determining the 
amount of haemoglobin, known as haemoglobi no meters or haemom- 
eters. 

Among these instruments that devised by Fleischl is undoubtedly 
the most convenient and has largely replaced the older forms of 
Gowers, Malassez, and Hayem. 

Estimation of Haemoglobin with Fleischl's Haemometer. — The princi- 
ple of the method depends upon the comparison of the color of the 
blood, diluted with water, with that of a glass wedge, stained with 
the golden purple of Cassius or a similar pigment. 

The instrument (Fig. 3) essentially consists of the glass wedge, a, 
just mentioned, to which a scale, b, is attached, ranging from to 
120, being placed at the thinnest, 120 at the thickest portion of 
the wedge. By means of a rack and pinion this can be made to slide 
from side to side beneath a platform corresponding to the stage of 
the microscope. In the center of the platform there is a circular 
opening into which artificial light (daylight is not permissible) is 
projected from a circular plate of plaster-of-Paris, mounted beneath, 
in the position of the mirror of the microscope. Into the circular 
opening a metallic tube, 1 .5 cm. in height, closed at the bottom with 
a plate of glass, and divided into two equal compartments by a 
metal partition, is fixed. One compartment receives the light 
through the glass wedge, the red chamber, the other directly from 
the plaster-of-Paris reflector, the white chamber. 

Capillary pipettes accompany the instrument and are of such a 
capacity that, if the blood of a perfectly normal individual is used, 
the mixture of blood and water, placed in the compartment receiving 
light directly from the white plate, shall correspond in color to that 
derived from the colored wedge at the mark 100. The two com- 
partments are partially filled with water, when the required amount 
of blood is obtained by placing one end of a capillary pipette in 
contact with a drop of blood obtained from the tip of a finger that 
has been carefully cleansed with water, alcohol, and finally with 
ether. The pipette is immersed in the white chamber and rotated 



32 



THE BLOOD. 



between two fingers, when the water will dissolve the haemoglobin 
from the corpuscles. Any trace of blood remaining in the pipette is 
carefully washed out with water, an ordinary medicine-dropper being 
used for the purpose. By means of the dropper the two compart- 
ments are then completely filled with water until a convex meniscus 
is obtained over the two chambers. A slip of paper is placed over 
the visible portion of the scale on the surface of the platform, imme- 
diately behind the well, c, and the glass wedge so adjusted by means 
of the screw that the color in the two chambers shall be the same. 



Fig. 3. 




v. Fleisehl's hfemometer. 

The number facing the notch in the scale-aperture of the platform 
will then indicate the percentage of haemoglobin, that of a healthy 
individual corresponding to 100. 

As the normal amount of haemoglobin in 100 grammes of blood 
is a little less than 14 grammes, the number 100 on the scale of 
Fleisehl's instrument corresponding to 13.7 per cent., the percentage 
in a given specimen may be calculated according to the equation : 
100 : 13.7 : : p : x, and x = 0.137 p, where p represents the reading 
on the scale and x the corresponding amount of haemoglobin in 100 
grammes of blood. 



CHEMICAL EXAMINATION OF THE BLOOD. 



33 



According to Dehio, certain errors are incurred in the estimation 
of haemoglobin by means of Fleischl's haemometer, which become the 
more marked the smaller the percentage. These may be obviated, 
however, and accurate results obtained, as far as such is possible, 
with the employment of colorimetric methods, if the instrument is 
previously tested with a solution of blood, the color of which accu- 
rately coincides with that of the wedge at the mark 100. To this 
end the standard solution is diluted with from 10 to 90 volumes of 
water, and any difference that may exist in the readings of the instru- 
ment, as compared with the known percentages, noted. 

If the number of red corpuscles is known, the amount of haemo- 
globin contained in each, " la valeur globulaire " of Lepine, can be 
readily determined, and is a point of considerable importance in 

Fig. 4. 






Gowers' hsemoglobiuometer. 



differential diagnosis. This determination is a simple matter, as it 
is only necessary to divide the percentage of haemoglobin by that of 
the red corpuscles. Supposing the amount of haemoglobin to have 
been fifty per cent., and the number of red corpuscles 4,000,000 per 
cubic millimeter, i. e., eighty per cent, of the normal (5,000,000), the 
color index would be fifty divided by eighty, /. c, 0.62. 

Under strictly normal conditions the color index is equivalent to 
1. Lower values are especially seen in chlorosis, where it may di- 
minish to 0.3 and even lower, but are also common in the secondary 
anaemias. Higher values, on the other hand, are practically only 
observed in pernicious ansemia, and are always suspicious. 

Estimation of Haemoglobin with Gowers' Haemoglobinometer. — 
Gowers' hsemoglobinometer is much cheaper than that of Fleisehl 



34 THE BLOOD. 

and yields results which compare favorably with those obtained with 
that instrument. The apparatus (Fig. 4) consists of: a closed tube 
(D), containing a solution of picrocarmine-glycerine, the color of 
which corresponds to a 1-per-cent. solution of normal blood ; a simi- 
lar tube (C), about 11 cm. in height, provided with an ascending 
scale of 134 divisions, each corresponding to 20 cbmm.; a capillary 
pipette (B), marked at 20 cbmm.; a guarded lancet (F); and a drop- 
ping-bottle with rubber top (A). 

In order to estimate the relative amount of haemoglobin in a given 
case the tip of a finger, or the lobe of the ear, is freely punctured, 
after having been cleansed as described above, and the pipette filled 
with blood to the 20 cbmm. mark. Any trace of blood that may 
adhere to the outer surface of the pipette is carefully wiped oif ; the 
contents are mixed at once with a few drops of distilled water, previ- 
ously placed in the graduated tube. In order to make the error in- 
curred, when this method is employed, as small as possible, care 
should be had to remove completely every trace of blood from the 
interior of the pipette by refilling it witli distilled water and blowing 
the contents into the graduated tube. The two tubes are then held 
side by side, directly against the light, or against a sheet of white 
paper, when water is added drop by drop, until the shade of color 
is the same in the two. The division on the scale ultimately reached 
will express the relative percentage of haemoglobin. 

The method of estimating the amount of haemoglobin from the 
specific gravity of the blood has been described on page 20. 

Estimation of Blood-iron with Jolles' Ferrometer. — The idea of esti- 
mating the haemoglobin from the blood-iron, as suggested by Jolles, 
has unfortunately not proven practical, as constant relations do not 
exist between the two bodies. This is owing to the fact that only a 
portion of the iron occurs in the form of haemoglobin. His method 
of estimating the total amount of iron in the blood deserves consid- 
eration nevertheless, as it may prove of practical value in clinical 
work. 

The principle of the method is the following : A small amount of 
blood is incinerated, and the remaining red oxide of iron brought 
into solution with a little monacid potassium sulphate. In this so- 
lution the iron is then estimated colorimetrically by means of a spe- 
cial apparatus — the ferrometer. As w T ill be seen from the accom- 
panying illustration (Fig. 5), this consists of two glass tubes C and 
C ', which are of the same diameter throughout, and closed at the 
bottom with small round glass plates, held in position by means of 
screws, as in the polarimetric tubes. Tube Ois of 15 c.c. capacity, 
while C is a little longer and holds about 16 c.c. Both are gradu- 
ated in half cubic centimeters. Tube C is provided with an over- 
flow tube near the bottom, which carries a stopcock. Both are fitted 



CHEMICAL EXAMINATION OF THE BLOOD. 



35 



into the perforated metallic plate (I)), and are surrounded by a cas- 
ing, so as to exclude all light from the sides. Below the plate is a 
plaster-of-Paris reflector, which can be turned with the screws K 
and K' '. Tube C receives the iron solution, obtained from the 
blood, and is closed with an accurately fitting glass disk, while in 
C is placed the iron solution used for comparison. This is allowed 
to flow away through the overflow tube (iJ), drop by drop, until the 
color in the two tubes is the same. But as the color in C , owing 
to the meniscus, which is formed, would be less sharply defined than 



Fig. 5. 




Jolles' Ferrometer. 



in C, the tube C is furnished with a cylindrical float of aluminum, 
which is closed above and below with glass disks. This float dis- 
lodges about one c.c. of fluid, and it is for this reason that C is 
made a little longer than C. 

A capillary pipette and the necessary additional apparatus, as well 
as reagents accompany the instrument, which is made by Reichert, 
of Vienna. 1 

Method. — In order to obtain the necessary amount of blood, viz, 
0.05 c.c, which is obtained by simple puncture of the finger or the 
ear, Jolles recommends that the capillary tube is first filled beywid 

'Of. late Jolles has devised a simpler apparatus than the one described, which i> 
likewise manufactured hv Keiehert. 



36 THE BLOOD. 

the mark and to close the pinchcock on the rubber tube at once. 
The excess of blood is then allowed to flow from the tube, and the 
tip is carefully wiped with filter paper. The 0.05 c.c. is placed in 
a platinum crucible, any traces that may remain adherent to the 
tube being washed out with a little distilled water. 1 

The blood is now evaporated to dryness over a plate of asbestos, 
at first with a small flame. The crucible is then placed on a pipe- 
stem triangle, and the residue carefully incinerated. One of the 
accompanying powders, containing 0.1 grin, of monacid potassium 
sulphate is now added. The mixture is cautiously heated with 
a small flame, until the powder begins to liquefy, when stronger 
heat is applied, and the mass congeals. This step is completed in 
one or two minutes. On cooling the material is washed into the 
cylinder C, through a small funnel with the aid of a little hot dis- 
tilled water, and diluted to the mark 10. The tube C is charged 
with one c.c. of the comparison-solution, and likewise filled to the 
mark 10 with hot distilled water. This solution contains 0.0005 
grm. of iron and 0.1 grin, of monacid potassium sulphate, in every 
cubic centimeter. 

To each cylinder are then added 1 c.c. of hydrochloric acid (1 : 3), 
and 4 c.c. of a solution of ammonium sulphocyanide (7.5 grms. pro 
litre). The tube C is now closed with the glass disk, care being 
taken to exclude bubbles of air, when the mixture is thoroughly 
shaken, and the tube fixed in the metallic plate. Tube C is likewise 
closed with a glass disk ; its contents are well agitated, the disk is 
removed and replaced by the carefully dried float. This should be 
placed upon the fluid slowly and with a screwing motion, so as to 
exclude bubbles of air. After this tube has also been placed in 
position the reflector is adjusted, and so much of the comparison- 
solution allowed to escape as to make the color in the two tubes the 
same. C is then removed from its base and the reading taken. In 
the table below the corresponding amount of iron in 1,000 c.c. of 
blood may be directly read off. Should it be desired to obtain the 
percentage by weight, the specific gravity of the blood should first be 
ascertained, and the necessary calculation made according to the 

equation D : V : : 100 : x, and x = l— t in which D represents the 

specific gravity, and V the percentage by volume. The resulting 
differences, however, are so small that they may be neglected, and 
for practical purposes it will be sufficient to assume a specific gravity 
of 1.050, and to read off the percentage by weight directly. To this 
end the second column in the table has been constructed. 

1 The pipette should always be cleansed immediately after use. It is best washed 
out with dilute sulphuric acid (10 per cent. ), then with dilute sodium hydrate solu- 
tion (5 per cent. ), and finally with alcohol and ether. 



CHEMICAL EXAMINATION OF THE BLOOD. 



37 



Table to Ascertain the Amount of Iron in 1,000 c.c. of 

Blood, and the Percentage by Weight, from 

the Number of c.c. of the Comparison 

Solution Used : 



C.c. of comparison 


Iron in 1,000 c.c. 


Iron-percentage 


solution used. 


of blood. 


by weight. 


15.0 


1.000 


0.0952 


14.5 


0.967 


0.0920 


14.0 


0.933 


0.0889 


13.5 


0.900 


0.0857 


13.0 


0.867 


0.0825 


12.5 


0.833 


0.0794 


12.0 


0.800 


0.0762 


11.5 


0.767 


0.0730 


11.0 


0.733 


0.0698 


10.5 


0.700 


0.0666 


10.0 


0.667 


0.0635 


9.5 


0.633 


0.0603 


9.0 


0.600 


0.0571 


8.5 


0.567 


0.0540 


8.0 


0.533 


0.0508 


7.5 


0.500 


0.0475 


7.0 


0.467 


0.0444 


6.5 


0.433 


0.0412 


6.0 


0.400 


0.0381 


5.5 


0.366 


0.0349 


5.0 


0.333 


0.0317 


4.5 


0.300 


0.0285 


4.0 


0.266 


0.0254 


3.5 


0.233 


0.0222 


3.0 


0.200 


0.0191 


2.5 


0.166 


0.0158 


2.0 


0.133 


0.0127 


1.5 


0.100 


0.0095 


1.0 


0.067 


0.0063 



Some of the results which have thus far been obtained are given 
in the following table : 



Normal ..... 

Chlorosis . . . . . 
Diabetes (severe) 

Carcinoma of uterus after hemorrhage 
Secondary an?emia 



Iron in 100 c.c. of blood 
by weight. 

. 0.0413-0.0559 

. 0.0203 

. 0.0292 

. 0.0152 

. 0.0177 



Jellineck, who has made a careful comparative study of the blood 
with Jolles' instrument and v. Fleischl's hsemometer, arrived at some 
very interesting conclusions. In diabetes he thus found that the 
amount of iron steadily diminishes, although the hsemoglobinometer 
gives higher readings. In a case of malaria the iron remained con- 
stant before and after the chill, while with v. Fleisehl's instrument 
variable results were obtained. In two eases oi' leucocytosis the 
ferrometer gave low readings, and in eight eases o\" secondary anae- 
mia, the hsemometer gave much higher values than the ferrometer. 



38 THE BLOOD. 

In a series of cases Jolles also examined into the presence of iron 
in the serum, by centrifugating a given volume of blood mixed with 
an 0.8-per-cent. salt solution, and found that in health the serum 
contains no iron. In three cases of chlorosis, in one case of leukae- 
mia, in one of neoplasm and one of interstitial nephritis, negative 
results were likewise reached. In two cases of severe diabetes, on 
the other hand, notable quantities were found. 

Hsemoglobinsemia. — The term hernoglobinemia has been ap- 
plied to a condition in which the hemoglobin is dissolved out from 
the red corpuscles, and, appearing in the plasma as such, leads at first 
to a very decided choluria and in extreme cases to hemoglobinuria. 

Various poisons, such as potassium chlorate, carbolic acid, pyro- 
gallic acid, naphthol, arsenic, sulphide of antimony, hydrochloric 
acid, sulphuric acid, antifebrin, antipyrin, phenacetin, sulphonal, 
tincture of iodine, when given hypodermically, or even internally in 
sufficiently large doses, will call forth a heruoglobineniia, which is 
followed by hemoglobinuria. 

Fresh morels also contain a poison which is capable of producing 
an intense hemoglobinuria, and which may be extracted with hot 
water. 

In acute and chronic infectious diseases of a severe type, such as 
scarlatina, typhoid fever, intermittent fever, icterus gravis, syphilis, 
as also in diseases depending upon a hemorrhagic diathesis, such as 
variola hemorrhagica, scurvy, as also following insolation, extensive 
burns, and frostbite, hemoglobinemia, leading to hemoglobinuria, is 
not infrequently observed. 

An epidemic hemoglobinuria of the newly born and a paroxysmal 
or intermittent hemoglobinuria, both of unknown origin, have like- 
wise been described. 

In a case of Raynaud's disease which I had occasion to observe in 
the clinic of Dr. H. M. Thomas, at the Johns Hopkins Hospital, 
hemoglobinuria at times followed epileptiform seizures. 

Hemoglobinemia followed by hemoglobinuria is finally observed 
after transfusion of the blood of one mammal into the circulation of 
another. 

In some cases, and particularly in those following poisoning with 
chlorates, etc., the hemoglobmemia ultimately leads to a well-pro- 
nounced methemoglobinemia (see below). 

A hemoglobinemia, aside from the urinary examination, may be 
readily recognized by a spectroscopic examination of the serum, when 
the two bands of absorption of oxyhemoglobin will be observed. 

A very simple method which may be employed for the same pur- 
pose is the following : A small amount of blood is drawn from the 
patient by means of cupping-glasses and immediately placed on ice, 
where it is allowed to remain for from twenty to twenty-four hours. 



CHEMICAL EXAMINATION OF THE BLOOD. 39 

At the expiration of this time the clot will have shrunk, floating, if 
the blood is normal, in the clear, straw-colored serum, while a 
beautiful ruby-red color is obtained in cases of haemoglobinaemia. If 
some of this serum is then heated to a temperature of from 70° to 
80° C, the coagulum in the presence of haemoglobin will present a 
more or less deep brown color. 

Carbon Monoxide Haemoglobin. — In cases of coal-gas poisoning 
the blood, both of arteries and veins, presents a bright cherry-red 
color, owing to the presence of carbon monoxide haemoglobin. 

Such blood, when properly diluted, like oxyhemoglobin, shows two 
bands of absorption between D and E (Fig. 6), which are nearer the 
violet end of the spectrum, however, and may be readily distinguished 
from those referable to oxyhemoglobin by the addition of a reducing 
agent. This will not affect the spectrum of carbon monoxide haemo- 
globin, while that of oxyhaemoglobin is transformed into the spectrum 
of reduced haemoglobin. 

For medico-legal purposes a number of additional tests have been 

Fig. 6. 
Bed Orange " Yellow Green Cyan-blue 



A a B C D Eb F 

40 50 60 70 80 90 100 110 

l llllllMlllll| ll JJllllllJjJ ll JlM 



ILL 




Spectrum of carbon monoxide haemoglobin, (v. Jaksch. ) 

devised, among which that suggested by Hoppe-Seyler is one of the 
simplest and at the same time most reliable. The blood is treated 
with double its own volume of a solution of sodium hydrate (sp. gr. 
1.3). Normal blood is thus changed into a dirty-brownish mass, 
which, when spread out upon a porcelain plate, exhibits a trace of 
green, while carbon monoxide blood yields a beautiful red under the 
same conditions. 

Nitric Oxide Haemoglobin. — The blood in cases of poisoning 
with nitric oxide, owing to the presence of nitric oxide haemoglobin, 
yields a spectrum which is similar to that of carbon monoxide haemo- 
globin ; the bands, however, are less sharply defined and paler than 
those of the latter and, like these, do not disappear on the addition 
of a reducing substance. 

Sulphuretted Hydrogen Haemoglobin (Methaemoglobin Sul- 
phide). — In cases of poisoning with sulphuretted hydrogen no def- 
inite changes can be discovered in the blood upon spectroscopic ex- 
amination, although Hoppe-Seyler has shown that haemoglobin may 
enter into combination with this gas. It is stated, however, that in 



40 THE BLOOD. 

such cases the blood becomes dark and of a dull greenish tint, and 
that the distinction between arterial and venous blood is lost. 

Carbon Dioxide Haemoglobin. — With carbon dioxide, as men- 
tioned above, haemoglobin is also thought to enter into combination, 
the spectrum being similar to that of reduced haemoglobin. The 
latter, in fact, is formed artificially when carbon dioxide is passed 
through a solution of oyxhaemoglobin. If this process is carried 
further, the haemoglobin is decomposed, and a precipitate of globulin 
thrown down ; an absorption-band is then obtained which is similar 
to that resulting when haemoglobin is decomposed with acids (see be- 
low). The question has hence arisen whether the so-called carbon 
dioxide haemoglobin spectrum is not in reality referable to carbon 
monoxide haemochromogen, the haemochromogen, according to Hoppe- 
Seyler, being the colored portion of the haemoglobin and its com- 
pounds with gases. 

Of the blood-changes occurring in cases of poisoning with hydro- 
cyanic acid and acetylene but little is known, and the reader is re- 
ferred to special works on toxicology for their consideration. 

Haematin. — If haemoglobin in aqueous solution is heated to a 
temperature of from 60° to 70° C, it is decomposed into an albu- 
minous body, belonging to the class of globulins, and haematin. The 
same result is also reached by treating the aqueous solution with 
acids, alkalies, or the salts of various heavy metals. 

Haematin is an amorphous, blackish-brown or bluish-black sub- 
stance which is frequently encountered in old transudates, in the 
stools after hemorrhages, and after meals rich in meats — i. e., blood. 
It is said to occur in the urine in cases of poisoning with arsenic, 
and in the blood of animals poisoned with nitrobenzol its presence 
can likewise be demonstrated with the spectroscope. 

In acid solutions it shows a well-defined spectral band between 
C and D (Fig. 9). Between D and F a second band is seen, which 
is much wider, but less sharply defined than the first, and may be 
resolved into two bands by dilution, one between b and F, near F, 
and another between D and E, near E; a faint fourth band may 
also be seen between D and E, near D. As a rule the two bands 
between D and F only are visible. 

In alkaline solutions it shows but one broad band, the greater 
portion of which lies between C and D, extending slightly beyond 
D (Fig. 7). 

If an alkaline solution of haematin is treated with a reducing 
substance, reduced haematin results, which gives rise to two bands 
of absorption between I) and E (Fig. 8). 

Hsemin. — Haematin readily combines with one molecule of hy- 
drochloric acid to form haemin. This substance crystallizes in light 
or dark brown rhombic plates or columns, which are highly charac- 



PLATE ; I 



FIG. 1. 



7'* 



Crystals of Hsemin. (Highly magnified/ 



FIG. 2. 




Vtf^S 



^7 



o&A » 



B^ 



\ si J 



N; 



Crystals Of Hseniatoidin from an Acholic Stool. 
(v. Jakseh.) 



CHEMICAL EXAMINATION OF THE BLOOD. 41 

teristic (Plate I., Fig. 1). They bear the name of their discoverer, 
Teichmann. The size of these crystals varies with the manner in 
which they are produced, the largest specimens being encountered 
w r hen the glacial acetic acid (see below) is allowed to evaporate as 
slowly as possible. Specimens measuring from 15 fi to 18 fi in 
length may then be seen. Smaller crystals will be present at the 

Fig. 7. 

Red Orange Yellow Green Cyan-blue 

A a B C D Eb F 

40 50 60 70 80 90 100 110 

iIiiiiIiiiiIiiiiIiiiiIiii.iJniiIiii iliiiilii|iliin In iiIiiiiIiii iln nlin 



Spectrum of hrematin in alkaline solution, (v. Jaksch. ) 

same time, occurring either singly or gathered in stars, rosettes, and 
crosses. 

As these crystals may be obtained from mere traces of blood, their 
formation must be regarded as conclusive evidence in medico-legal 
examinations. Lewin and Rosenstein have pointed out, however, 
that under certain conditions a negative result may be reached, even 
if the coloring-matter is derived from the blood. This is the case 
especially when the haemoglobin has been transformed into haBmo- 
chromogen or hsematoporphyrin, or when substances have been mixed 
with the blood which are either capable of altering its general com- 
position or which, through their mere presence, interfere with the 
reaction. Such substances are certain salts of iron (rust), lead, mer- 

Fig. 8. 

Red Orange Yellow Green Oyan-blue 

A a B C D Eb F 

40 50 60 70 80 90 100 HO 



I I I II I I 



Spectrum of reduced hsematin. (v. Jaksch. 

cury, and silver; further, lime, animal charcoal, and sand, when 
these are intimately mixed with the blood. In medico-legal eases a 
spectroscopic examination should hence also be made whenever the 
hseniin reaction is not obtained. 

Method. — A small drop of normal salt-solution is carefully 
evaporated on a slide, when a few particles ot' the suspected material. 



42 



THE BLOOD. 



powdered or teased as finely as possible, are placed upon the delicate 
layer of crystallized salt. The preparation is covered with a cover- 
glass, and glacial acetic acid allowed to just fill the space between the 
two glasses. The specimen is then carefully heated (three-quarters 
to one minute) until bubbles of gas begin to form beneath the cover. 
While evaporation is being continued glacial acetic acid is further 
added, drop by drop from the edge of the slip, until a faint reddish- 
brown tint appears. As soon as this point is reached the last traces 
of the acid are allowed to evaporate, the specimen being held at a 
greater distance from the flame. A drop of glycerin is finally added, 
when the preparation may be examined under the microscope, atten- 
tion being directed especially to any reddish-brown streaks or specks, 
which, in the presence of blood, can usually be made out with the 
naked eye. 

Methaemoglobin. — Methemoglobin is a pigment closely related to 
oxyhemoglobin, and is frequently encountered in sanguinous transu- 
dates, cystic fluids, and in the urine in cases of hematuria and hemo- 



Bed 


Orange Yellow 


Fig 


9. 

Green Cyan-blue 


A 


a 
Mil 


B C D E 

40 50 60 70 80 

inli iiiliiiilinil iiiiIiii ill ii iltniliml 


b F 

90 100 110 

















Spectrum of methsemoglobin in acid and neutral solutions, (v. Jaksch.) 



globinuria. In the circulating blood methsemoglobin is found after 
the ingestion of large quantities of potassium chlorate, notably so in 
children, as also after the inhalation of nitrite of amyl, the use of 
kairin, thallin, hydrochinon, pyrocatechin, iodine, bromine, turpen- 
tine, ether, perosmic acid, permanganate of potassium, and antifebrin. 
(See Heruoglobinemia, p. 38.) 

The spectrum of an aqueous or slightly acidified solution of methse- 
moglobin (Fig. 9) closely resembles that of an acid solution of hema- 
tin, but differs from this in the ease with which it is transformed 
into that of hemoglobin when an alkali and a reducing substance are 
added. The spectrum of hernatin under the same conditions is 
transformed into that of an alkaline solution of heniochromogen. In 
alkaline solutions, on the other hand, two bands of absorption are 
observed, which are similar to those of oxyhemoglobin, but differ 
from these in the fact that the band nearer E, /?, is more pronounced 
than the one at D, a. A third, but very faint, band may further be 
observed between C and D, near D. 

Hsematoidin. — Small amorphous particles of an orange or ruby- 



CHEMICAL EXAMINATION OF THE BLOOD. 



4.3 



red color, or crystals belonging to the rhombic system (Plate I., Fig. 
2), occurring either singly or in groups, are frequently met with in 
the sputum, the urine, and the feces, as well as in old extravasations 
of blood. They were first discovered by Virchow, who applied the 
term hsematoidin to this particular pigment, the hsemic origin of 
which is undoubted, being probably derived from hsematin. 

Haematoporphyrin. — Hsematoporphyrin is likewise a derivative 
of hsematin, and, according to Nencki and Sieber, isomeric with 
bilirubin. In dilute solution with sodium carbonate it shows four 
bands of absorption, one between C and D, a second one, broader 
than the first, about D, especially marked between D and E, a third 
one, not so broad and less sharply defined between D and E, and a 
fourth one, broad and dark, between b and F (Fig. 10). 

The clinical significance of this body, which also appears in the 
urine, as well as the causes giving rise to its formation, are as yet 
unknown. (See Hsematoporphyrinuria.) 

While it is usually possible, as pointed out above, to recognize 



Fig. 10. 



Red Orange Yellow 



Cyan-blue 




Spectrum of hseinatoporphyrin in alkaline solution. 



definitely the presence of blood by the hsemin-test, recourse should 
always be had to a spectroscopic examination whenever the exact 
nature of the pigment under consideration is to be determined. 

The Spectroscope. — The spectroscope (Fig. 11) essentially con- 
sists of a tube (A), provided with a slit at its distal end, which may 
be narrowed or widened, and a collecting-lens at its proximal end. 
Through the latter rays of sunlight or of artificial light are thrown 
upon a prism (P), where they are decomposed into a colored spec- 
trum which is viewed through an astronomical telescope (B). 
Through a third tube (C) a fine scale, illuminated by artificial light, 
is reflected by the prism to the eye of the observer, appearing im- 
mediately above the colored spectrum. The left end of this is red, 
passing into yellow, this into green, then into blue, indigo, and finally 
into violet, which occupies the right end. These colors, however. 
are not continuous, but are interrupted by a large number of verti- 
cally placed dark lines, named after Frauenhofer. The most marked 
of these are designated by the letters: A, a, />, (\ D, 1\, 6, /'. G, 



44 



THE BLOOD. 



and H. Of these, A is found at the left end and B in the middle 
of the red portion of the spectrum, C at the boundary of the red and 



Fig. 11. 




The spectroscope. (Neubatjer.) 



the orange, D in the yellow, E in the green, F in the blue, G in the 
indigo, and H in the violet portion ; a is situated in the red between 



Fig. 12. 





Browning's spectroscope. (Zeiss.) 



A and B, nearer J., and b in the green between E and F, nearer 
E. (See Fig. 1.) 



THE PRO TEWS OF THE BLOOD. 45 

If now a colored medium is placed between the slit and the light, 
not all the rays of colored light reach the eye, but some become ab- 
sorbed. In the case of the blood, for example, it may thus be seen 
that a portion of the yellow and a portion of the red rays are ab- 
sorbed, a spectrum of this kind being spoken of as an absorption- 
spectrum. 

For cliuical purposes various instruments, modifications of the one 
described, have been devised, among which those of Desego of 
Heidelberg, Zeiss of Jena (Fig. 12), and Hoffman of Paris as well 
as Hering's lenseless spectroscope, and Henocque's instrument, are 
quite serviceable. 

THE PROTEIDS OF THE BLOOD. 

In considering the proteids of the blood from a clinical point of 
view, it is necessary to distinguish between an increase and a diminu- 
tion in their normal amount, constituting the conditions of hyper- 
albuminosis and hypalbuminosis, respectively. As may be expected, 
the former is met with whenever water is more rapidly withdrawn 
from the system than it can be supplied, and is hence observed in 
cases of cholera, acute diarrhoea, following the use of purgatives, etc. 
This increase in the amount of proteids is only a relative increase, 
however. The occurrence of an absolute increase has not as yet been 
satisfactorily demonstrated. An absolute hypalbuminosis, on the 
other hand, is observed following a direct loss of proteids from the 
blood, as in hemorrhage, dysentery, albuminuria of high degree, the 
formation of large collections of pus, etc. This is generally associated 
with a relative increase in the amount of water — i. e., a hydremia, 
which is particularly noticeable after hemorrhages, and referable to 
a diminished secretion and excretion of water, as well as to a direct 
absorption from the tissues. 

The term hyperinosis has been applied to a condition in which the 
amount of fibrin is increased. This is said to occur in various 
inflammatory diseases, such as pneumonia, pleurisy, acute articular 
rheumatism, and erysipelas, while a diminished amount of fibrin, 
hypinosis, has been observed in malaria, nephritis, pyaemia, and per- 
nicious anaemia. 

In order to determine the amount of fibrin, 30 to 40 c.c. of blood, 
obtained by means of cupping-glasses, are placed in a previously 
weighed beaker, fitted with an India-rubber cap, through the center 
of which passes a piece of whalebone, firmly fixed. The blood is 
defibrinated by beating with the whalebone, when the beaker with 
its contents is weighed, the difference indicating the weight of the 
blood. The beaker is then filled with water and the mixture again 
beaten. The fibrin is then allowed to settle and after being washed 



46 THE BLOOD. 

with normal salt-solution filtered through a filter of known weight. 
It is further washed with normal salt-solution until free from color- 
ing matter, then boiled in alcohol to dissolve out the fat, cholesterin, 
and lecithin, dried at 110° to 120° C, and weighed on cooling over 
sulphuric acid. 

In leukaemic blood v. Jaksch was able to demonstrate peptones in 
considerable quantities, and especially so after death, when the amount 
progressively increased as decomposition advanced. Matthes, on 
the other hand, could detect no true peptones, but found that the 
blood contained a deuteroalbumose. In one case the serum con- 
tained an abundance of nucleoalbumin, derived in all probability 
from degenerated leucocytes. 

More recently albumoses have also been found in a case of abscess 
of the brain, associated with albumosuria. 

Following the injection of nuclein and spermin, moreover, albu- 
mossemia appears to occur quite constantly both during the stage of 
hypo- as well as hyperleucocytosis. After injections of pilocarpin 
albumosuria is only observed in association with hyperleucocytosis. 

In order to test for albumoses, all other proteids should first be 
removed, when a positive biuret-reaction in the filtrate will indicate 
their presence. (See also Salkowski's test.) 

Carbohydrates. 

Sugar. — Sugar, as indicated above, is a normal constituent of the 
blood, its quantity varying between 1 and 1.5 p. m. Under patho- 
logic conditions this amount may be exceeded by far, and notably so 
in diabetes, in which Hoppe-Seyler found as much as 9 p. m. in a 
given case. 

In addition to sugar, a non-fermentable reducing substance has 
been encountered in the blood, the exact nature of which is still un- 
known. 

Large quantities of a reducing substance, the greater portion of 
which consisted of sugar, have been met with by Trinkler in carci- 
noma ; it was observed at the same time that carcinoma of the inter- 
nal organs was associated with far greater amounts of sugar than 
cancerous diseases of the skin and the mucous membranes. It is 
also interesting to note in this connection that an increase in the de- 
gree of the cachexia was not accompanied by an increase in the per- 
centage of sugar. 

The results reached by Trinkler apparently also bear out the cor- 
rectness of the conclusions formed by Freund, who claimed that a 
differential diagnosis between carcinoma and sarcoma, in which latter 
condition no increase in the amount of sugar was noted, can always 
be effected upon the basis of an examination of the blood in this 
direction. 



THE PROTEIDS OF THE BLOOD. 47 

In the following table the percentages found in the different dis- 
eases investigated are given, from which it is apparent that next to 
carcinoma the largest quantities of sugar are met with in the infec- 
tious diseases and the lowest figures in diseases of the kidneys : 





Average. 


Minimum. 


Maximum, 




Per cent. 


Per cent. 


Per cent. 


Carcinoma 


. 0.1819 


0.1023 


0.3030 


Typhoid fever . 


. 0.0950 


0.0875 


0.1022 


Pneumonia 


. 0.0943 


0.0813 


0.1092 


Dysentery 


. 0.0838 


0.0796 


0.0915 


Heart disease . 


. 0.0737 


0.0664 


0.0897 


Peritonitis 


. 0.0701 


0.0450 


0.0917 


Tuberculosis 


. 0.0653 


0.0450 


0.0817 


Syphilis . 


. 0.0553 


0.0449 


0.0748 


Nephritis and uraemia 


. 0.0489 


0.0321 


0.0559 



In order to demonstrate sugar in the blood, 15 to 30 grammes, 
obtained by venesection or cupping-glasses, are placed in an evapor- 
ating-dish and treated with an equal weight of finely powdered 
sodium sulphate and a few drops of acetic acid. The mixture is 
brought to the boiling-point and passed through a muslin filter as soon 
as the coagulum has become black and spongy, water having been 
previously added to the original volume. The filtrate is passed 
through Swedish paper. In the final filtrate the sugar is then esti- 
mated as described elsewhere. (See Urine.) 

Or, the blood is treated with four to five times its volume of strong 
alcohol (94 to 96 per cent.), slightly acidified with acetic acid. The 
mixture is allowed to stand for several hours, no heat being applied. 
It is then filtered and evaporated on the water-bath until all the 
alcohol has been driven off. Should any albumin separate out during 
this process, the residue is again extracted with alcohol. The final 
residue is dissolved in water. In this solution the sugar is then 
estimated according to Knapp's method. 

Of late Cavazzani has drawn attention to another method of free- 
ing the blood from proteids which is said to be entirely satisfactory 
and less expensive. To this end 20 to 30 c.c. of blood are added to 
200 c.c. of distilled water in a porcelain dish and treated with five 
or six drops of a solution consisting of 10 parts of acetic acid (sp. 
gr. 1.040) and 1 part of lactic acid. The mixture is boiled for eight 
to ten minutes, filtered, and the coagulum Avashed repeatedly with 
hot water and finally pressed out in a piece of muslin. The result- 
ing filtrates, which are practically colorless, are then concentrated to 
a small volume, and any traces of albumin, which may still separate 
'out, filtered off. If too much of the acid solution has been added, it 
may happen that the mixture does not clear up on boiling. It is 
then only necessary to add a tow crystals of sodium carbonate, when 
coagulation will occur at once. On the other hand, it may at times 
be necessary to add a few more drops of the acetic acid solution. 



48 THE BLOOD. 

Williamson's Diabetic Blood-test. — This test is of much interest 
and may possibly serve to differentiate the ordinary forms of dia- 
betes from that in which the blood sugar is not increased. It is 
based upon the observation that a warm alkaline solution of methy- 
lene blue is decolorized by grape sugar. As with Bremer's test, 
(see p. 63), a positive result may at times be obtained, when the sugar 
has temporarily disappeared from the urine. 

Method. — 20 cbmm. of blood, obtained from the finger or the 
ear, are carefully measured off with the aid of the capillary pipette, 
which accompanies Gower's hsemocytometer, and are mixed in a test- 
tube of small caliber with 40 cbmm. of distilled water. To this 
mixture one cubic-centimeter of an aqueous solution of methylene 
blue (1: 6,000), and 40 cbmm. of a 6-per-cent. aqueous solution of 
potassium hydrate are added. A control tube is similarly charged 
with non-diabetic blood. The two specimens are then placed in 
boiling water and allowed to remain for from 3 to 4 minutes, without 
shaking. At the end of this time it will be seen that the diabetic 
blood has decolorized the methylene-blue solution, which has turned 
a yellowish-green, or yellow, while the non-diabetic specimen has 
retained its original color. 

The quantity of blood used should not exceed the amount indi- 
cated, as a decolorization of the methylene blue also results with 
non-diabetic blood, if large amounts, such as 60 cbmm. are employed. 

Glycogen. — There appears to be no doubt that glycogen normally 
occurs in the blood of various animals. Huppert succeeded in dem- 
onstrating its presence in all animals examined, the amount varying 
between 0.114 and 1.560 grammes for one hundred parts of blood. 
Czerny, on the other hand, was not able to confirm these results in 
the case of healthy adults, while in sick children an examination of 
the leucocytes furnished positive results, glycogen being met with in 
chronic gastro-intestinal diseases, pneumonia, anaemia, furunculosis, 
cachectic conditions the result of tubercular disease, asphyxia, etc. 
In diabetes and leukaemia the glycogen-reaction is said to be quite 
pronounced. 

Livierato, who recently investigated this question with great care, 
arrived at the following conclusions : 1. Glycogen is constantly 
present in the blood of healthy individuals ; its presence, however, 
is confined to the blood-plasma. When present in increased amounts 
it also occurs in the leucocytes. 2. It is absent in cases of acute 
articular rheumatism and in inflammatory conditions of the serous 
membranes. 3. Increased amounts are found in acute croupous 
pneumonia, in typhoid fever, in phthisis, and in various exanthe- 
mata, etc. 4. In hepatic and cardiac diseases associated with 
effusion it is either absent or present in traces. 5. An endo- 
globular reaction only may be obtained during the second half 



THE PROTEWS OF THE BLOOD. 49 

-of the ninth month of pregnancy and during the first four or five 
days of the puerperal period. 6. An increase in the amount of gly- 
cogen is dependent upon the existence of an active local lesion, asso- 
ciated with fever, upon the formation of exudates containing pep- 
tonizable material, or upon the existence of a more or less pronounced 
hyperleucocytosis. According to Kaminer it is commonly seen in 
puerperal fever. A positive reaction is also obtained in severe con- 
tusions and fractures — two to three days after the injury, — in rapidly 
progressing staphylococcus and streptococcus infections, and follow- 
ing narcosis. 

Ehrlich explains the appearance of glycogen in the leucocytes by 
assuming that this is present in every cell as a colorless compound, 
from which the glycogen is easily split off and may then be demon- 
strated as such. 

In order to test for glycogen it is best to spread a drop of blood 
between two cover-glasses and to place the air-dried specimens in a 
small jar containing a few crystals of iodine. After several minutes 
the blood films assume a dark brown color, when they are mounted 
in a drop of a saturated solution of hevulose and examined with an 
oil-immersion lens. The red corpuscles are stained the color of 
iodine, while the leucocytes are almost colorless. All glycogen gran- 
ules, whether these are contained in leucocytes or free in the blood, 
are stained a distinct mahogany. Ehrlich suggests that this method 
be used more extensively in the study of diabetes and other diseases. 
It certainly furnishes far better results than the old staining with a so- 
lution composed of 1 gramme of iodine and 3 grammes of potassium 
iodide in 100 grammes of a concentrated solution of mucilage. He 
also states that the same method may be very advantageously used 
in testing for glycogen in the secretions, as in gonorrhoeal pus, 
tumor-cells, etc. 

Cellulose. — Cellulose has occasionally been found in the blood of 
tubercular patients. 

Urea. 

Urea normally occurs in the blood in traces — 0.016 to 0.020 per 
cent. Larger amounts are encountered whenever, for any reason, as 
in nephritis, various diseases of the urinary organs, cholera Asiatioa. 
cholera infantum, eclampsia, etc., its elimination is impeded, or when- 
ever, as in fever, owing to increased albuminous decomposition, urea 
is formed in abnormally large quantities. 

In this connection it is interesting to note that a smaller amount 
of urea is found in fatal eases of eclampsia than in those ending in 
recovery, an observation which has been explained by the assumption 
that in this condition the functional activity, not only of the kidneys, 
but also of the liver, is lost. 
4 



50 THE BLOOD. 

The methods which are available for the detection of urea in the 
blood are still too complicated for clinical purposes, and the value 
of the information derived so small as hardly to repay for the labor 
involved. Hoppe-Seyler's method should be employed whenever an 
examination in this direction is deemed advisable. 1 

Uraemia. — Formerly it was thought that the complex of symp- 
toms generally spoken of as uraemia was referable to the retention 
in the blood of urea or ammonium carbonate. This view has since 
been disproven, however, although it must be admitted that in 
uraemia an increased amount of urea is frequently noted. Other 
views, according to which uraemia is referable to an accumulation 
of potassium salts, of extractives, and especially of kreatinin, or of 
ptomains in the blood, must still be regarded as being sub judice. 
There is no reason, however, to ascribe the uraemic condition to the 
retention in the blood of one particular constituent of the urine, and 
it is not at all improbable that a retention of all may be responsible 
for the symptoms observed. 

Ammonia. 

Normal venous blood, according to the researches of Winterberg, 
contains about 1 mgrm. of ammonia for every 100 c.c. In febrile 
conditions variable results are obtained, but it appears certain that 
a definite relation between the height of the fever and the amount of 
ammonia does not exist. In chronic hepatic diseases, and notably 
in cirrhosis, it is not increased. The course of acute yellow atrophy 
also is not necessarily associated with an increase. Very significant 
is the observation that in uraemia following extirpation of the kid- 
neys no increase is observed. An ammoniaemia in the sense of v. 
Jaksch can hence scarcely be said to exist. 

Uric Acid and the Xanthin-bases. 

Uric Acid. — Formerly, the presence of appreciable amounts of 
uric acid in the blood was regarded as pathognomonic of gout. But 
we now know that a lithaemic condition may also occur in other 
diseases. 

A definite lithaemia has been observed in a variety of disorders, 
such as pneumonia, acute and chronic nephritis, chronic gastritis, 
catarrhal angina, conditions associated with an insufficient aeration 
of the blood, as in the various diseases of the heart, in pleurisy with 
exudation, emphysema, when accompanied by cyanosis, the severer 
forms of anaemia, etc. v. Jaksch claims to have found uric acid in 
the blood in 88.88 per cent, of his cases of nephritis. Fever in 
itself does not appear to lead to an increased production of uric acid, 

1 See Hoppe-Seyler : Handbucli der physiologisch- und pathologisch-chemischen 
Analyse. Vierte Auflage, p. 363. , 



THE PROTEWS OF THE BLOOD. 51 

as negative results were obtained in nine cases of typhoid fever out 
of eleven, in five cases of acute articular rheumatism out of six, etc. 
The conclusion is thus forced upon us that the diminished alkalinity 
of the blood observed in nephritis and anyemia is, to some extent at 
least, dependent upon the presence of a nitrogenous acid, while the 
diminished alkalinity of the blood observed in fevers is not referable 
to this cause. 

From a survey of the literature upon the subject it appears that 
an increased elimination of uric acid in the urine is not necessarily 
accompanied by an increase in the amount of uric acid in the blood. 
Further researches in this direction are, however, highly desirable, 
and particularly so in connection with the various forms of gastric 
disease, in which an increased elimination of uric acid, according to 
my experience, is so frequently observed. 

The assumption that the acute attacks of gout are referable to an 
increased alkalinity of the blood, and a consequent increase in the 
amount of uric acid has been disproven. 

In order to test for uric acid in the blood the following method 
may be employed : 100 to 300 c.c. of blood obtained by means of 
cupping-glasses, are at once diluted with three or four times their 
own volume of water and heated on the water-bath. As soon as 
coagulation sets in a few drops of an 0.3- to 0.5-per-cent. solution of 
acetic acid are added until a feebly acid reaction is obtained. After 
having been kept upon the boiling-water bath for from fifteen to 
twenty minutes longer, until the albumin has separated out and 
settled in brownish flakes, the mixture is filtered, while hot, and the 
precipitate washed repeatedly with hot water. Filtrate and washings, 
which usually present a slightly yellow or brownish color, are again 
brought to the boiling-point after the addition of 0.3 to 0.5 per cent, 
of acetic acid, decanted, filtered, and after the addition of a small 
amount of disodic phosphate further treated according to the Lud- 
wig-Salkowsky method (see Urine). The first filtrate is then treated 
with hydrochloric acid, evaporated to about 10 c.c, and allowed to 
stand for twenty-four hours, when the uric acid that has separated 
out is filtered off through asbestos or glass-wool. The filtrate may 
then be examined for xanthin-bases according to the same method. 
If no uric acid crystallizes out, as not infrequently occurs, the acid 
fluid is directly examined for uric acid by means of the murexid-test 
(which see). If, upon the addition of ammonia, no distinct red color 
develops, the residue, after thorough desiccation, is dissolved in water, 
when a reddish color may bo regarded as indicating the presence o{ 
uric acid, while a yellow or brown color is referable to xanthin-bases. 
Hopkins' method may also be used. 

Garrod's Test: This test may be advantageously employed if it is 
merely desired to determine whether or not large amounts o( uric 



52 THE BLOOD. 

acid are present in the blood. A few c.c. of blood-serum (5—10) or 
of serous fluid, obtained by means of a blister, are placed in a watch- 
crystal and treated with from G to 10 drops of a 30-per-cent. solu- 
tion of acetic acid. A thread of linen is immersed in the fluid, which 
is then kept at a low temperature for from twelve to twenty-four 
hours. At the expiration of this time a few uric-acid crystals will 
have separated out upon the thread, if the substance is present in 
large amounts. The true nature of these crystals may then be 
further determined by the microscope and the murexid-test. (See 
Uric Acid in the Urine.) 

Xanthin-bases. — Xanthin-bases do not occur in normal blood, but 
have been encountered under pathologic conditions, as in typhoid 
fever, lymphatic tuberculosis, emphysema, phthisis pulmonalis, 
pleurisy, and chronic nephritis. 

The method above indicated for the demonstration of uric acid in 
the blood should also be employed when it is found desirable to test 
for these bodies. (See Urine.) 

Fat and Fatty Acids. 

An increase in the amount of fat which is normally present in the 
blood, to the extent of 0.2—0.3 per cent., aside from that arising after 
the ingestion of large amounts of fatty food, is met with in cases of 
obesity, chronic alcoholism, injuries affecting the long bones and the 
spinal cord, in severe cases of diabetes, various hepatic diseases, 
chronic nephritis, tuberculosis, malaria, cholera, etc. This increase 
constitutes the condition spoken of as lipcemia. The term lipacidcemia 
has been applied to the occurrence of volatile fatty acids in the blood, 
noted by v. Jaksch in various febrile diseases, leukaemia, and at 
times in diabetes, in which this condition is supposed to stand in a 
causative relation to the coma. /9-oxybutyric acid has been found 
post mortem in the blood in diabetes. 

To demonstrate the presence of fat in the blood it is best to pre- 
pare cover-glass specimens, and to mount these in a drop of a 5-per- 
cent, solution of osmic acid. The fat droplets are thus colored black, 
and appear about as large as the finest fat granules which are found 
in milk or butter. They may also be stained with Sudan III. and 
are thus colored red. In every case the necessary instruments and 
glasses should be carefully cleansed with ether, so as to avoid an 
accidental introduction of fat. 

To test for fatty acids 20 to 30 c.c. of blood, obtained by means of 
cupping-glasses, are treated with an equivalent weight of sodium 
sulphate and boiled. The filtrate is then evaporated to dryness and 
extracted with absolute alcohol. Upon evaporation of this solution 
fatty acid crystals will be obtained, which can be readily recognized 
with the microscope. (See Feces.) 



THE PROTEIDS OF THE BLOOD. 53 

Lactic Acid. 

There appears to be some doubt whether or not lactic acid nor- 
mally occurs in the blood of man during life, while after death its 
presence is fairly constant, the amount determined as zinc lactate 
varying between 0.233 and 6.575 p. m. In the series of cases 
studied by Irisawa it was impossible to account for the great varia- 
tions in the amount of lactic acid by the character of the disease 
causing the fatal termination, and it is possible that the cause there- 
fore lies in the fact that in some cases the blood was obtained shortly 
after death, while in others many hours had elapsed, as Irisawa 
himself suggests. 

The following method may be employed : 100 to 300 c.c. of blood 
are extracted with three times its volume of alcohol, filtered, and 
the filtrate evaporated to a syrupy consistence. This is then made 
strongly alkaline with barium hydrate and shaken with large quanti- 
ties of ether, in order to remove the fats which are present. The 
residue is acidified with phosphoric acid and again shaken with ether 
for twenty minutes at a time, until the process has been repeated 
five or six times, the lactic acid passing over into the ether. The 
ether is distilled off from the extract, the residue taken up with 
water, and the solution carefully evaporated in order to drive off any 
ether still remaining, as well as the fatty acids. Carbonate of zinc 
is now added and the solution heated to 100° C. and filtered. The 
filtrate is evaporated on the water-bath until crystallization begins, 
when it is allowed to cool and treated with a few drops of absolute 
alcohol, in order to effect a complete separation of the lactate of zinc. 
The solution is allowed to stand exposed to the air until a constant 
weight is obtained. 

From the blood of living dogs Irisawa was able to obtain lactic 
acid in every case, and it was observed that the amount stood in a 
direct relation to the degree of anaemia produced. 

Biliary Constituents. 

Biliary constituents, i. e., bile-pigment and biliary acids — are not 
encountered in the blood under normal conditions, but are found 
whenever they are present in the urine (which see). It is note- 
worthy, furthermore, that bilirubin may frequently be demonstrated 
in the blood when a urinary examination in this direction yields 
negative results. According to v. Jaksch, moreover, bilirubin occurs 
in the blood in nearly every case in which urobilin exists in the urine, 
showing that bile-pigment circulating in the blood is, in all proba- 
bility, transformed into urobilin in the kidneys, 

A ehokemia is encountered in the various pathologic conditions 
which are associated with a resorption of bile, as in obstructive jaun- 



54 THE BLOOD. 

dice, in association with an excessive elimination of bile into the in- 
testinal canal, as well as with an increased destruction of red cor- 
puscles. 

In order to test for biliary acids the blood is first treated with 
alcohol, in order to remove the proteids. The biliary acids which 
are present in the filtrate are next transformed into their lead salts 
by means of acetate of lead and ammonia, and thus precipitated. 
After washing with water the precipitate is boiled with alcohol and 
filtered. The lead salts are decomposed by means of sodium carbo- 
nate, the solution is again filtered, the filtrate evaporated to dryness, 
and the residue extracted with absolute alcohol. The alcohol is dis- 
tilled off, when the biliary salts of sodium will crystallize out or re- 
main behind as an amorphous mass, which may be tested directly 
according to Pettenkofer's method. To this end some of the residue 
is dissolved in water and treated with two-thirds of its volume of 
concentrated sulphuric acid, care being taken that the temperature 
does not rise beyond 60° C. To this mixture a few drops of a 20- 
per-cent. solution of cane-sugar are added, when in the presence of 
biliary acids a beautiful violet color is obtained, which is referable to 
the action of furfurol, formed from the cane-sugar and the acid, upon 
the biliary acids. 

Bilirubin can be demonstrated in the blood most readily in the 
following manner: 10 to 15 c.c. of blood obtained by means of 
cupping-glasses, are allowed to coagulate, when the serum is re- 
moved by means of a pipette, filtered through asbestos, and coagu- 
lated in as thin a layer as possible, at a temperature of 80° C. 
Under such conditions normal serum will present a light straw color, 
while in the presence of biliary coloring-matter a light-greenish 
color is obtained, which becomes grass-green on standing. Should 
the serum contain haemoglobin, as in cases of ha?moglobina?mia, a 
brownish color results. 

Acetone. 

Acetone has been found in the blood in considerable amounts 
under various pathologic conditions, and especially in fevers. 

In order to demonstrate its presence the blood is first extracted 
with ether and subsequently distilled, when the distillate is tested as 
indicated elsewhere. (See Acetonuria.) 

Dmnige's test may also be employed, and has the advantage of 
greater simplicity : Three cubic centimetres of blood are treated 
with about 30 c.c. of Dennige's reagent and left to stand, until 
the dark brown precipitate has settled to the bottom. The super- 
natant fluid is filtered off, and treated with a little more of the 
reagent, so as to insure complete precipitation. It is then acidified 
with sulphuric acid and heated as described. The formation of a 



PLATE II, 



FIG. 1. 



fep^o # 



r O 







^ 



^ fc > ^ 



tf 



o 



• Q 



•-./-■/ 



: 



o 



- 



j 






,D 




J 



o" * 






Elements of Normal 
Blood. 

i, Small Mononuclear Leucocyte ; 
2, Neutrophilic Leucocytes; 3, Eosino- 
philic Leucocyte ; 4, Normal Red Blood 
Corpuscles. Unstained Specimen. 



Poikiloeytosis. 

Unstained Specimen taken from a 
Case of Pernicious Anaemia. (Per- 
sonal Observations.) 



FIG. 2. 




%*r %£ 



S» 4 



m 







CO € 

Oflr 



go; 






OS 

L. Schmidt fecvt ^^p 



P°£© 



Q 



O 



© 



© 



05 



© 






The Various Elements of the Blood Stained with Ehrlieh's Tri-aeid Stain. 

e, Small Mononuclear Leucocytes ; 2, Large Mononuclear Leucocytes; 3, Transition Form ; 4, Neutrophilic 

Leucocytes; 5, Myelocyte; 6. Eosinophilic Leucocyte; 7, Melaniferous Leucocyte; 8, Normoblast; 

9, Megaloblast ; 10, Normal Red Corpuscles. (Personal Observation.) 



MICROSCOPIC EXAMINATION OF THE BLOOD. 55 

white precipitate, which is soluble in an excess of hydrochloric acid, 
is referable to acetone or diacetic acid. 



MICROSCOPIC EXAMINATION OF THE BLOOD. 

The Red Corpuscles. , 

Variations in the Size of the Red Corpuscles. — If a drop of 
blood, most readily obtained from the tip of a finger or the lobe of 
the ear, is examined with the microscope, a large number of faintly 
greenish-yellow, non-nucleated, circular, biconcave disks will be ob- 
served : the red corpuscles, or erythrocytes of the blood (Plate II., 

Under normal conditions variations in the size of the red corpuscles 
are observed, and Hayem distinguishes between corpuscles of aver- 
age size, measuring from 7.2 p to 7.8 p in diameter, small corpuscles, 
presenting an average diameter of from 6 p to 6.5 p, and large cor- 
puscles, measuring from 8.5 p to 9 p. 

In certain diseases which are acccompanied by a marked oligo- 
cythemia both abnormally small and large corpuscles are encoun- 
tered, which have been termed microcytes and mdcrocytes, respectively. 
The former measure from 3.5 p to 6 p, the latter from 9.5 p to 12 p 
in diameter. Still larger forms, the megalocytes, or giant corpuscles 
of Hayem, are also seen at times, in which the diameter measures 
from 10 p to 1Q p. These latter are of especial interest, as their 
presence in large numbers appears to be confined almost entirely to 
the blood of pernicious anaemia. In chlorosis they are far less 
common. 

The terms microcythcemia and macrocythcemia have been applied to 
conditions in which the smaller or the larger forms respectively, pre- 
dominate in the blood. While there appears to be no doubt that a 
true macrocythsemia exists in the circulating blood in various forms 
of ansemia, and while microcytes also may occur, as such, in the cir- 
culating blood, these are only exceptionally met with, the ordinary 
microcythaamic condition, according to Hayem, being artificially 
produced during the preparation of the specimen, so that this term 
really conveys a wrong impression, and should be discarded. Al- 
though admitting; the correctness of Havem's view to a certain degree, 
there can be no doubt that, under pathologic conditions, abnormally 
small red corpuscles are quite constantly met with in large numbers, 
be they pre-existent, as such, in the circulating blood, or produced 
artificially during the preparation of the specimen. They are thus 
seen accompanying the condition of macrocythsemia, in pernicious 
amentia, leukaemia, the pseudo-lenksemic condition of children, the 
various severe forms of anaemia in general, and even in chlorosis. 



56 THE BLOOD. 

Variations in the Form of the Red Corpuscles. — Going hand in 
hand with variations in the size of the red corpuscles are variations 
in form which affect not only the microcytes and macrocytes, but also 
the corpuscles of normal size (Plate II., Fig. 1, b). Corpuscles 
are thus seen which resemble a flask, a kidney, a biscuit, a boat, a 
balloon, a dumb-bell, an anvil, etc., while others, again, are so ir- 
regular in appearance that it is impossible to compare them with any 
known object. Very characteristic also are the oval red corpuscles, 
which are so commonly seen in pernicious anaemia. Especially in- 
teresting is the fact that such corpuscles may manifest certain move- 
ments, in the fresh preparation, and that they have been mistaken at 
times for amoeba? and similar organisms. 

The term poikilocytosis has been applied to alterations both in the 
size and in the form of the red corpuscles. This condition may be ob- 
served in the various forms of anaemia, and is especially pronounced in 
pernicious anaemia, of which disease it was once thought to be pathog- 
nomonic. In chlorosis, poikilocytosis is usually only seen in the most 
severe cases, and particularly in those manifesting a tendency toward 
thrombosis and embolism. 

Variations in the Number of the Red Corpuscles. — The num- 
ber of red corpuscles in the blood of healthy individuals is fairly 
constant, and the statement generally found in text-books that 5,- 
000,000 to 5,500,000 are contained in every cbmm. of blood in the 
adult male and 4,500,000 in the adult female is fairly accurate. 

A somewhat higher average is found among people living at a 
considerable elevation above the sea level, and it is interesting to 
note that an increase in the number occurs whenever a change in the 
habitation is made from a lower to a higher level. This increase is 
very frequently most marked, as is apparent from the following 
table, taken from Ehrlich : 

Altitude. Increase of. 

561 ni 800,000 

700 m 1,000,000 

1,800 m 2,000,000 

4,392 m 3,000,000 

A corresponding diminution occurs when the change is made from 
a higher to a lower level. 

An apparent increase in the number of red corpuscles may be met 
with in all those conditions, in which a concentration of the blood, 
as a whole, occurs, as in profuse diarrhoea, vomiting and sweating, 
in connection with the rapid accumulation of ~serous effusions, dur- 
ing starvation, viz, the withdrawal of liquids, etc. In such cases 
counts of 6,000,000 and more may be obtained. There are still 
other conditions, however, in which an apparent increase in the num- 



MICROSCOPIC EXAMINATION OF THE BLOOD. 57 

berof the red corpuscles occurs, and in which this increase is not due 
to a concentration of the blood as a whole. This is notably the case 
in diseases of the adrenal glands, where counts of 6,000,000 and 
7,000,000 have been repeatedly obtained, although the color index 
of the individual corpuscles is distinctly subnormal. The supposi- 
tion is that in such cases a stasis of large quantities of the blood 
occurs in the abdominal viscera, leading to oligemia of the periph- 
eral organs. But in consequence of the fact that the amount of 
plasma, which is available for the nutrition of these parts, corre- 
sponds to a smaller amount of blood, a localized concentration occurs, 
of which the polycythemia is the outcome. 

An increase is further observed in diabetes, but is not depend- 
ent upon a concentration of the blood, as it may also be seen follow- 
ing an increased ingestion of fluids, as well as while fasting. While 
there can thus be no doubt that a polycythemia may occur, experi- 
ments have demonstrated almost exclusively that such a condition 
does not exist in what is generally spoken of as true plethora, and 
that the various symptoms of plethora, formerly attributed to an in- 
crease in the total amount of blood, or of the red corpuscles, are ref- 
erable, more likely, to vasomotor disturbances. 

A diminution in the number of red corpuscles, on the other hand, 
is more frequently observed ; it may be temporary, or permanent. 
An oligocythemia is observed in various forms of anemia, of what- 
ever origin, and the number may fall to 360,000 and even lower in 
fatal cases. In pernicious anemia the lowest figures have been 
noted, and Quincke cites a case in which just before death only 
143,000 red corpuscles were counted in the cbmm. 

When the anemia is progressive the body apparently becomes 
habituated to the diminution in the number of the red corpuscles, and 
it is surprising to find individuals attending to the duties of everyday 
life with a blood count of only 2,000,000, or even less. It is not 
uncommon even to meet with cases of pernicious anemia in hospitals 
in which the patients with only 500,000 corpuscles have not been 
obliged to go to bed. Nevertheless it must be admitted that, when- 
ever the number falls below this figure, recovery is probably out of 
the question. A sudden reduction in their number to 1,000,000, 
moreover, is usually followed by a fatal result. 

In chlorosis the oligocythemia is generally not marked. Cabot thus 
found 4,050,000 red corpuscles per cbmm. as the average, in his se- 
ries of 77 cases — in other words, nearly normal values. At times, 
however, cases are met with in which the diminution of the red cor- 
puscle almost keeps step with the diminution in the amount of 
hemoglobin. Hayem thus mentions an instance of chlorosis, in 
which only 1)37,360 were counted in the cbmm. Such cases, o\' 
course, are rare. 



58 THE BLOOD. 

In leukaemia a more than moderate oligocythemia is likewise not 
the rule, and more common in the lymphatic than in the myeloge- 
nous form. The average figures, which Cabot gives, are 2,730,000 
and 3,120,000 respectively. 

In Hodffkin's disease a marked diminution is also unusual. 

In the secondary auaemia, even in advanced cases, the oligocy- 
themia may not be very marked, excepting the anaemias of infancy 
and early childhood, following profuse hemorrhages, in malaria and 
in acute septicaemia. 

The post-typhoid anaemia is, as a rule, not very severe, but ex- 
ceptional cases occur in which the diminution in the number of the 
red corpuscles is considerable. Osier thus cites an instance in which 
the number fell to 1,300,000 per cubic millimetre. 

Very important is the fact that in acute gastritis and usually in 
chronic gastritis, also, the number of red corpuscles is not dimin- 
ished, while in carcinoma a marked oligocythaemia exists. In the 
severer forms of chronic gastritis a diminution is fairly constant, but 
rarely so marked as in carcinoma, if we except those cases of gas- 
tric anadeny which present the clinical picture of a pernicious anaemia. 
In ulcer of the stomach normal values are found unless haematemesis 
has recently occurred or unless the disease is associated with pro- 
found chlorosis. 

Variations in the Color of the Red Corpuscles. — As the intensity 
of the color of the individual corpuscle depends upon the amount of 
haemoglobin which it contains, and is more marked along the pe- 
riphery than in the centre, a deficiency of haemoglobin may be recog- 
nized at once. In a moderate grade of anaemia the entire corpuscle 
will thus appear paler than normally, and the pallor will naturally 
be more marked in the centre. In the severer forms this becomes 
still more apparent, and corpuscles may then be met with, in which 
a narrow rim of haemoglobin can only be discerned along the pe- 
riphery, while the centre appears colorless. Such forms have very 
appropriately been compared to pessaries and are hence spoken of as 
" pessary forms/' This appearance can be readily made out upon 
examination of a fresh specimen, but is especially marked in stained 
preparations. 

Curiously discolored red corpuscles, presenting a bronzed appear- 
ance, are frequently observed in malarial blood. Their presence 
should always excite suspicion, and lead to a careful examination for 
malarial organisms. The discoloration is in all probability evidence 
of a degenerative process. 

Behavior toward Anilin Dyes. — Under normal conditions the 
red corpuscles can only be stained with acid dyes, such as eosin, 
orauge G, and others. In various forms of anaemia on the other 
hand this property is lost to a greater or less extent, while a certain 



MICROSCOPIC EXAMINATION OF THE BLOOD. 59 

affinity for basic stains becomes manifest. This is readily seen in 
blood specimens, which have been taken from cases of chronic ansemia, 
and have been stained with hgemotoxylin-eosin or eosin-methylene blue 
(see pp. 71 and 73). In such preparations the majority of the red 
corpuscles will be stained a pure eosin, but individual corpuscles will 
also be seen in which the blue tint of the hematoxylin is more or less 
apparent. In some a blue tint can thus be made out only indistinctly, 
while others show a very manifest bluish-red color, and still others 
are stained a reddish-blue. Similar pictures are obtained with 
Ehrlichias tri-acid stain/ but are not as well defined. This altered 
behavior of the red corpuscles toward the anilin dyes has been 
ascribed to certain degenerative processes, wdiich take place in the 
red blood-corpuscles, and the phenomenon has hence been termed 
ancemic or polychromatophilic degeneration. 

As I have already indicated this degeneration is observed in various 
forms of anaemia, and may affect not only the non-nucleated, but also 
the nucleated red corpuscles, and especially the megaloblasts (see 
p. 61). The peculiar coppery tint of some of the red corpuscles, 
which is so frequently observed in malarial blood, is probably also 
referable to this origin. 

Very interesting and important is the observation of Bremer, that 
a distinct difference exists in the affinity of diabetic blood for certain 
anilin dyes, as compared with non-diabetic blood. For, whereas 
non-diabetic blood is readily stained with Congo-red, methyl-blue, 
eosin, etc., diabetic blood is distinctly refractory, while such dyes as 
Biebrich-scarlet, which readily stain the diabetic blood, do not color 
non-diabetic blood. Upon this peculiarity in the behavior of the 
red corpuscles Bremer's diabetic Mood test is based. 

Method : A drop of blood of moderate size is mounted on a slide 
and spread out in a wave-like manner, using the edge of a second 
slide for this purpose. A number of such preparations are made, as 
also an equal number with normal blood for control. These are then 
placed on the tray of a drying oven, at a distance of 12 centimetres 
from the bottom. The bulb of the thermometer is fixed at the same 
level. The temperature is then rapidly raised to about 130° C, when 
the flame is turned off. Care should be taken that the temperature 
thereafter does not exceed 140° C. ; the optimum lies at about 135° 
C. The apparatus is then allowed to cool, until the specimens can 
be conveniently handled, when a specimen of the diabetic blood is 
placed back to back with a control-specimen, and both are immersed 
in the staining fluid. To this end a one-per-eent. aqueous solution 
of Congo-red, which should always be made up freshly, when re- 
quired, is very convenient. After exposure for from one and a-half to 
two minutes, the specimens are rinsed in water and dried with filter 
paper. It will then be seen that the non-diabetic blood is stained 



60 THE BLOOD. 

the color of Congo-red, while the diabetic blood is either not stained 
at all, or merely presents an orange color. 

Other stains may also be employed, such as a one-per-cent. aqueous 
solution of methyl-blue or Biebrich scarlet, or Ehrlich's tri-acid stain 
and others. When using; methyl-blue, analogous results are obtained 
as with Congo-red. AYith Biebrich scarlet, on the other hand, the 
diabetic blood takes up the color, while the non-diabetic specimen 
proves refractory. If Ehrlich's stain is employed an exposure to the 
stain for from two to five minutes is necessary ; the diabetic speci- 
men is stained orange, the non-diabetic blood violet. 

Very pretty pictures are also obtained with the following method : 
The preparations are first stained for from one and a-half to two 
minutes in a one-per-cent. aqueous solution of methyl-green. Upon 
washing it will be seen that both specimens are colored green, but 
the diabetic blood more markedly so, than the other. Both are then 
immersed for from eight to ten seconds in a |-per-cent. aqueous so- 
lution of eosin, when the diabetic blood remains green, while the 
non-diabetic specimen is colored eosin. Analogous results are 
obtained with methylene blue and eosin. 

Success in these examinations depends essentially upon the proper 
degree of temperature during the process of fixation. But care 
should also be had not to leave the specimens in the staining solu- 
tion longer than indicated, and to quickly rinse in water and dry. 

I have used this method in ten cases of diabetes with very satis- 
factory results, and have likewise obtained a positive reaction at 
times, when the sugar had temporarily disappeared from the urine. 
As a control to the urinary examination the method is certainly of 
value and may possibly prove even more important. 

Regarding the nature of the substance in diabetic blood, which is 
responsible for this peculiar behavior, little is known, but it appears 
certain that the reaction is not dependent upon the presence of glu- 
cose nor upon the degree of alkalinity of the blood, as suggested by 
Lepine and Lyonnet. Bremer's claim that the reaction is pathogno- 
monic of diabetes and glycosuria, and may even yield positive results 
in the pre-diabetic stage of the disease, and when the sugar has 
temporarily disappeared from the urine, has been confirmed in all 
essential poiuts, both in this country and abroad. A few interesting 
exceptions, however, have been noted. In animals, for example, in 
which glycosuria has been artificially produced by means of phlorrhi- 
zin, the reaction does not occur, whereas in phloroglucin-diabetes, 
positive results are obtained. In Bremer's entire series of diabetic 
cases, a negative result was obtained but once, and in this instance 
he believes that the diabetes was of the renal type, and analogous to 
the phlorrhizin-diabetes of animals. He suggests that it may thus 
be possible to differentiate this form from the hematogenic variety, 



PLATE III. 




jtmm&:- 



O. w 




The Blood of Pernicious Ansemia. 

Note (a) the variations in the size and form of the red corpuscles; (6) the existence of polychromato- 
philic and granular degeneration in some of the red corpuscles; (c) the presence of nucleated red corpuscles, 
both of the normoblastic and megaloblastic type; (d) the presence of free nuclei, derived from nucleated red 
corpuscles. (Bausch and Lomb, Eye-piece i inch, objective, i-i2th.) 



MICROSCOPIC EXAMINATION OF THE BLOOD. 61 

using the latter term in the widest sense of its meaning. Lepine and 
Lyon net report a positive result in one case of leukaemia, but Bremer 
believes this to have been referable to faulty technique. 

Granular Degeneration of the Red Corpuscles. — In certain dis- 
eases, notably in pernicious anaemia, leukaemia, severe septic infec- 
tions, tuberculosis, carcinoma, malaria and syphilis, associated with 
cachexia, following profuse hemorrhages, in chronic lead poisoning, 
when associated with intestinal symptoms, etc., red corpuscles have 
been encountered, which contain basophilic granules in variable 
numbers. They can be readily demonstrated by staining with Jen- 
ner's stain or with Ehrlich's haematoxylin-eosin solution, and appear 
as intensely blue granules of variable size and form. While the 
majority are round, others are rod-like or biscuit-shaped and fre- 
quently arranged in pairs, resembling gonococci in appearance. As 
a general rule they are seen in the interior of red blood-corpuscles, 
but I have also found them free in the plasma (Plate III.). Gra- 
witz states that he has observed these granules in cells of normal 
size and coloration, but that they also occur in megalocytes, micro- 
cytes, small poikilocytes and even in nucleated red corpuscles. 
Some of the cells were undergoing polychromatophilic degeneration. 
As a result of his investigations he concludes that the occurrence of 
these granules is not referable to a process of nuclear destruction, as 
Ehrlich and Engel suggest, as nucleated red corpuscles are not nec- 
essarily present at the same time, and as granular red cells are not 
found in the bone-marrow, even in individuals, where they were 
numerous in the circulating blood. He is therefore inclined to re- 
gard their occurrence as indicating some degenerative process in the 
haemoglobin, and has termed this "granular degeneration." 

Schmauch has observed similar appearances in the blood of cats, 
and, like Engel, who found them in the blood of early cat-embryos, 
believes that they are referable to karyolysis. 

I have seen the same granules in the red corpuscles in a case of 
pernicious anaemia and one of lymphatic leukaemia, but have not 
been able to convince myself that a relation exists betAveen their ap- 
pearance and nuclear destruction. In the case of pernicious ansemia 
I found them extremely numerous and usually in cells, which pre- 
sented a well marked polychromatophilic degeneration. To my 
mind they are unquestionably indicative of cell destruction, but, like 
Grawitz, I do not believe that the polychromatophilia represents an 
early stage of granular destruction. 

Nucleated Red Corpuscles. — Three varieties of nucleated red 
corpuscles may he seen. For their study, however, dried and stained 
preparations are indispensable, as the nuclei can scarcely he made out 
in fresh specimens. 

1. Normoblasts : These are nucleated red corpuscles of the si/e 



62 THE BLOOD. 

of an ordinary red corpuscle, and appear to be identical with those 
normally found in the bone-marrow of adults. The nucleus, which 
frequently shows signs of undergoing division, is usually located 
centrally, although an excentric position may also occur. They are 
further characterized by the great avidity with which the nuclei take 
up the nuclear dyes (Plate II., Fig. 2, Plates III. and IV.). 

Free nuclei, which are undoubtedly also derived from normoblasts, 
may likewise be seen in the blood. 

Normoblastic red corpuscles are quite constantly found in all 
forms of severe anaemia, whether this be the result of traumatism, of 
inanition, or organic disease. In the acute anaemias they are apt to 
be most numerous, but even in the chronic forms and in cachectic 
conditions specimens of blood may be obtained, in which one or more 
are seen in almost every field. In his recent work on Anaemia 
Ehrlich cites a case of hemorrhagic anaemia, reported by v. Noorden, 
in which temporarily the normoblasts were so numerous, while hyper- 
leucocytosis existed at the same time, that the blood closely resembled 
that seen in myelogenous leukaemia. As this condition was associated 
with an increase of the red corpuscles to almost double their original 
number v. Noorden very aptly termed it a " blood crisis." 

For the accurate determination of a blood crisis the following ex- 
aminations are necessary : 

a. A determination of the absolute number of the red corpuscles. 

b. A determination of the ratio between the white and red cells. 

c. A determination of the ratio between the nucleated red and 
white cells, in dried specimens, with the aid of the quadratic ocular 
diaphragm. 

Example : Supposing that in a given case 3,500,000 red corpus- 
cles are found in the cbmm., while the ratio of the white to the red 
corpuscles is 1 : 100, and that of the nucleated red to the white 1:10; 
3,500 nucleated red corpuscles must hence be present in every cbmm. 
of blood, i. e., one for every thousand normal red corpuscles. 

Whenever the number of red corpuscles falls below 1,500,000 and 
normoblastic cells are not present, the disease will probably end 
fatally. 

2. Megaloblasts : These bodies are from two to four times as large 
as the normal red corpuscles, and are provided with a large nucleus, 
which, according to Ehrlich, never shows signs of undergoing division, 
and does not stain nearly so deeply as the normoblastic nucleus 
(Plate II., Fig. 2, and Plate III.). In some specimens indeed the 
affinity for nuclear dyes is so little marked, that at first sight a 
nucleus can scarcely be discerned. 

At times abnormally large megaloblasts are seen — the giganto- 
blads of Ehrlich. 

In contradistinction to the normoblasts, megaloblasts are never 



PLATE IV. 




An 



%j 



*#<#§ 



o I ° 

I 




O' 








The Blood of Myelogenous Leukaemia. 

Note the large increase of the leucocytes, and the presence of nucleated red corpuscles of the normoblastic 
type. In addition to the leucocytes, found in normal blood, viz.. small and large mononuclear leu 
dcv. .id of granules, and of polynuclear neutrophilic and eosinophilic leucocytes, myelocytes, both of the neu- 
trophilic and eosinophilic variety, are also seen. (Bausch and Lomb 



MICROSCOPIC EXAMINATION OF THE BLOOD. 63 

found in traumatic anaemia, and even in the chronic anaemias of the 
severest grade they are scarcely ever seen. Even in leukaemia 
they are usually absent. In pernicious anaemia, on the other hand, 
even in the early stages of the disease, they are quite constantly pres- 
ent, although they are usually not numerous. As the megaloblasts 
are normally only found in foetal bone marrow, Ehrlich views their 
presence in the blood as a symptom of retrogressive metamorphosis 
and of very grave prognostic import. The only exception to this 
general rule is that form of pernicious anaemia which is at times ob- 
served in association with the presence of bothriocephali in the in- 
testinal tract. In one case of this kind, reported by Askanazy, 
the megaloblastic type of blood regeneration disappeared after the 
expulsion of the parasites — 67 in number, and was replaced by the 
normoblastic type, the case ending in recovery. From this observa- 
tion Askanazy concluded that a material difference does not exist be- 
tween normoblasts and megaloblasts, and that the former develop 
from the latter. But, as Ehrlich maintains, it is certainly more 
likely that the megaloblastic degeneration of the bone marrow is ref- 
erable directly to the action of certain toxins, and that such a rela- 
tion between the normoblasts and megaloblasts, as Askanazy as- 
sumes, does not exist. 

3. Microblasts: These are unusually small nucleated red corpuscles, 
and only rarely observed. They have been found in cases of trau- 
matic anaemia, but have so far attracted but little attention. 

The Leucocytes. 

The leucocytes, or white corpuscles of the blood, as seen in freshly 
prepared specimens, are roundish or irregularly shaped cells and 
mostly larger than the red corpuscles. They are nucleated, and 
many are distinctly granular in appearance, so much so, in fact, that 
the nuclei are often hidden from view (Plate II., Fig. 1, a). In a 
carefully spread specimen some leucocytes will be met with which 
are endowed with the power of locomotion, creeping over the field of 
vision by throwing out pseudopodia, in a manner analogous to that 
seen in amoebae. In their general mode of living the motile leuco- 
cytes, moreover, closely resemble amoebae, and it is most interesting 
to observe the manner in which these little bodies take up cellular 
debris, and even obnoxious organisms that may be present in the blood. 
In malarial blood, for example, in which, as will be shown later, cer- 
tain amoebic parasites are present, one is frequently able to observe 
leucocytes approach these bodies and take them up into their interior 
(Fig. 13). Metschnikoff regards this function of the leucocytes as 
their most important one. Those leucocytes which possess this 
power of removing foreign matter from the blood he has termed 
phagocytes, and according to his views the outcome of a bacterial in- 



64 



THE BLOOD. 



vasion. 



figuratively speaking, will depend upon the superiority of 
the organisms engaged in warfare. The term phagocytosis has been 
applied to the destruction of micro-organisms by leucocytes. 

General Differentiation of the Various Forms of Leucocytes. 
— Upon ordinary microscopic examination three varieties of leuco- 
cytes can be distinguished (Plate II., Fig. 1, a). Some are round, 
smaller than the red corpuscles, and provided with a large round 
nucleus, which is surrounded with a very narrow rim of non-granular 
protoplasm. Others are met with which are likewise round, of the 



Fig. 13. 






Phagocytosis. 

size of an ordinary red corpuscle, or somewhat larger, and contain a 
large single nucleus which is surrounded by a wider zone of non- 
granular protoplasm. The largest cells, the bodies of which are 
filled with granular material, often hiding the nucleus from view, 
are representatives of the third variety. 

Upon further examination differences may also be demonstrated 
in the character of the granulations. Some leucocytes will thus be 
observed in which these are very fine, giving the entire body of the 
cell a somewhat cloudy appearance, and usually obscuring the nu- 
cleus. This may be brought into view, however, by treating the 



PLATE V. 






J " •C % " f 






*li* 







\ 






o 



f 



I 

Infill 



NOchmtdf. |>f. 



The Blood of Lymphatic Leukaemia. 



Note the large increase of the lymphocytes. Two of the red corpuscles are undergoing granular 

degeneration ; in a few others polychromatophilia can be discerned. 

(Bausch and Lomb, Eye-piece i inch, objective, i-i2th.) 



MICROSCOPIC EXAMINATION OF THE BLOOD. 65 

preparation with a drop or two of a one-per-cent. solution of acetic 
acid. On the other hand, very coarse granulations may be observed 
in certain leucocytes, while still others, as already pointed out, are 
apparently non-granular. 

Ehrlich, in studying these various granulations in their behavior 
toward anilin dyes, found that different chemical affinities exist be- 
tween these minute particles of protoplasm and the reagents em- 
ployed. Some are thus only colored by acid dyes, others again only 
by those of a basic nature, while still others are stained only by 
neutral dyes. These observations are of the greatest importance 
from a clinical standpoint, and have indeed revolutionized the entire 
field of hematology. 

The Anilin Dyes. — Ehrlich divides the acid dyes derived from 
coal-tar into two large groups : i. e., into dyes which will color cer- 
tain granulations even when employed in concentrated solutions of 
glycerine, and into those which can only be employed in aqueous so- 
lutions. 

The first group comprises : 

(1) The highly acid bodies belonging to the fluorescin series, viz, 
eosin, methyl-eosin, erythrosin, coccin, pyrosin J and R ; (2) the 
highly acid nitro-bodies, such as aurantia ; (3) the two groups of 
sulpho-acids, i. e., indulin, bengalin, and nigrosin, on the one hand, 
and the azo-stains, tropseolin, Bordeaux, and Ponceau, on the other. 

The second group comprises : 

(1) Fluorescin and chrysolin ; (2) ammonium picrate and naph- 
thyl-amin-yellow ; (3) orange and true yellow. 

Representatives of the basic stains are : fuchsin (rosanilin), the 
methyl derivatives of rosanilin, viz, methyl-violet, methyl-green, 
etc., the phenyl derivatives of rosanilin, rosonaphthylamin, cyanin, 
safranin, etc. 

As an example of a neutral stain there may be mentioned the pi- 
crate of rosanilin. 

Differentiation of the Leucocytes According to their Behavior To- 
ward the Anilin Dyes. — According to their behavior toward these 
various pigments Ehrlich has divided the granular leucocytes found 
in the blood into eosinophilic, or oxyphilic, basophilic, and neutro- 
philic leucocytes. By the aid of his method the following forms 
can be distinguished in the blood (Plate IT., Fig. 2, Plates III., IV. 
and V.). 

1. Small Mononuclear Leucocytes. — These are mostly 
smaller than the red corpuscles or of equal size. They are devoid 
of granular matter, each cell being provided with a large, homoge- 
neous and uniformly staining nucleus, which is surrounded by a nar- 
row rim of protoplasm. In the larger forms especially, a taint 
areola may sometimes be scon between the nucleus and the proto- 



66 THE BLOOD. 

plasm, which is probably owing to artificial retraction. Nucleus and 
protoplasm both are basophilic, but such that with certain dyes the 
protoplasm is colored much more deeply than the nucleus. Within 
the nucleus one or two nucleoli can sometimes be seen. The pe- 
riphery of the larger forms is usually shaggy in appearance, and it 
is not uncommon to find particles of protoplasm in the circulating 
blood which have apparently separated from this peripheral margin. 
In stained specimens the origin of these particles may be recognized 
from their color, which coincides with that of the parent corpuscles. 
As the protoplasm of the small mononuclear leucocytes bears no 
affinity for acid or neutral dyes, these elements merely appear as 
faintly stained, apparently free nuclei, in specimens colored with the 
tri-acid stain (see p. 86). The reaction of the protoplasm, as shown 
with the erythrosin method, is strongly alkaline (p. 90). It con- 
tains no glycogen. At times, though rarely, an invagination of the 
nucleus may be observed indicating the beginning division of the 
cell. The nuclear figures which result, however, differ materially 
from those seen in the true polynuclear elements. Abnormally large 
forms are at times seen in lymphatic leukaemia, and may even occur in 
the blood of normal infants, but it is scarcely likely that their true 
nature will be overlooked, if the characteristics just described are 
borne in mind. 

As the small mononuclear leucocytes are practically only formed 
in the lymph glands, they have been termed lymphogenic leucocytes 
or lymphocytes. 

Under normal conditions the lymphocytes constitute from 22 to 
25 per cent, of the total number of leucocytes. 

Under pathologic conditions the greatest absolute as well as rela- 
tive increase is observed in cases of lymphatic leukaemia. A relative 
increase occurs in healthy infants, in various diseases of infancy, 
notably those affecting the gastro-intestinal tract, in chlorosis, per- 
nicious anaemia, secondary syphilis, in the late stages of typhoid 
fever, in certain cases of Basedow's disease, haemophilia, goitre, etc. 
(see also p. 32). 

2. Large Mononuclear Leucocytes. — These are from two to 
three times as large as the red corpuscles, and provided with a large 
single nucleus, which is oval or elliptical in form, and surrounded by 
a wide zone of non-granular protoplasm. In specimens, stained 
with the tri-acid stain, beginners are very apt to overlook this form, 
as the nucleus and particularly the protoplasm are often very faintly 
stained. The nucleus and protoplasm are both basophilic, but the 
latter, in contradistinction to the protoplasm of the lymphocytes, less 
so than the nucleus. 

These forms are by some thought to represent a later stage in the 
development of the small mononuclear variety, but Ehrlich still 



MICROSCOPIC EXAMINATION OF THE BLOOD. 67 

maintains their independent origin from the bone marrow, and to some 
extent perhaps also from the spleen. 

They occur in increased numbers in cases of chronic malaria, in 
measles, at the end of scarlet fever, and in many of the diseases in 
which the small mononuclear elements are increased. I have met 
with a considerable relative increase of this variety in one case of 
Addison's disease, shortly before death. In one of my patients, a 
lady aged 63, attention was first directed to the existence of a large 
sloughing epithelioma of the neck by the discovery of 21 per cent, 
of the large mononuclear leucocytes. 

Under normal conditions the percentage varies between one and two. 

3. Transition Forms. — These develop directly from the large 
mononuclear leucocytes. They are still mononuclear, but the nucleus 
is greatly invaginated, indicating approaching division. As a gen- 
eral rule no granules are observed, but at times they do occur, when 
they are neutrophilic in character. In specimens stained with the 
tri-acid stain the nucleus is colored somewhat deeper than in the 
second variety. 

Together with the large mononuclear elements they constitute from 
two to four per cent, of the total number of leucocytes. 

4. The Neutrophilic Polynuclear Leucocytes. — These 
cells are a little smaller than the large mononuclear leucocytes and 
the transition forms, and filled with very fine neutrophilic granules, 
the £-granulation of Ehrlich. The nucleus is a long body, which is 
twisted upon itself into irregular forms, sometimes resembling the 
letters S, Y, E, and Z. At other times it presents a broken appear- 
ance, conveying the impression as though several nuclei were present. 
Hence their original name — polynuclear leucocytes. As Ehrlich has 
suggested, however, the polynuclear appearance is probably referable 
to post-mortem changes, the condition of the nucleus being in reality 
polymorphous. In accordance with this view they are hence also 
spoken of as the polymorpho -nuclear neutrophilic leucocytes. The 
nucleus stains readily with all nuclear dyes, while the protoplasm 
shows a marked affinity for the greater number of acid dyes. Its 
reaction, as tested with acid erythrosin, is alkaline, but less so than 
the protoplasm of the lymphocytes. In health a glycogen reaction 
is not obtained. 

According to some observers the polymorphonuclear neutrophilic 
leucocytes represent a later stage in the development of the small 
and large mononuclear cells. Ehrlich, on the other hand, insists 
that the greater number enters the blood from the bone-marrow, 
where they develop from the mononuclear neutrophilic leucocytes — 
the myelocytes — or bone-marrow cells proper (which see, p. 70), but 
admits that a small number is derived directly from the transitional 
forms in the blood current. 



68 THE BLOOD. 

In this connection it is especially interesting to note that while 
basophilic and oxyphilic granules are found in the blood of all verte- 
brate animals the neutrophilic granulation only occurs in man and 
the ape. 

Normally the polynuclear neutrophilic leucocytes constitute from 
70 to 72 per cent, of all leucocytes. 

The most common forms of hyperleucocytosis are referable to an 
increase in the number of these elements (see p. 72). All pus cor- 
puscles, moreover, according to Ehrlich, belong to this class. 

5. The Oxyphilic or Eosinophilic Leucocytes. — In size and 
general appearance these cells resemble the polynuclear neutrophilic 
leucocytes. But they differ from these in the absence of neutrophilic 
granules, and the presence, instead, of large, ovoid or roundish, 
highly refractive, fat-like granules — the a-granulation of Ehrlich. 
These granules only take up acid dyes, such as eosin and acid fuch- 
sin, and the leucocytes have hence been termed oxyphilic or eosino- 
philic leucocytes. Like the polynuclear neutrophilic leucocytes they 
are also phagocytic. 

According to some observers the eosinophilic leucocytes represent 
the senile stage in the development of the small mononuclear leuco- 
cytes. But Ehrlich still regards them as independent bodies, formed 
in the bone-marrow from mononuclear eosinophilic cells, analogous 
to the formation of the polynuclear neutrophilic leucocytes from the 
mononuclear neutrophilic cells. 

Normally the percentage of eosinophilic leucocytes varies between 
two and four. 

An absolute increase in their number is observed in all uncompli- 
cated cases of myelogenous leukaemia, while a relative increase is 
inconstant. Statements to the contrary have been made by many 
observers, but, as Ehrlich suggests, this is undoubtedly owing to a 
confusion between the terms absolute and relative. According to 
Zappert 50 to 100 eosinophilic leucocytes in the cbmm. of blood 
should be regarded as the lowest normal values, 100 to 200 as the 
average, and 200 to 250 as the highest normal figures. Supposing 
then that in a given case the percentage of eosinophils is 3.5 per 
cent. This would of course be a perfectly normal percentage. But, 
if at the same time the total number of leucocytes is 400,000, it is 
apparent at once that we are dealing with a considerable absolute 
increase, corresponding in this case to 14,000 eosinophilic leucocytes, 
i. e., an increase of 56 times the maximum number observed under 
normal conditions. It may be stated as a general rule that whenever 
an absolute increase in the number of the eosinophilic leucocytes is not 
found in a case of supposed myelogenous leuhcemia this diagnosis may 
be abandoned, providing that complications, such as septic processes, 
do not exist at the same time. In sepsis the number of eosinophilic 



MICROSCOPIC EXAMINATION OF THE BLOOD. 69 

leucocytes is very materially diminished, and in some cases they may 
be altogether absent. Exceptions, however, also occur, and Ehrlich 
cites a case, where the total number was still from 1,400 to 1,500 in 
the cbmm., although the percentage had diminished from 3.5 to 0.43. 

Aside from myelogenous leukaemia an increase in the number of 
the eosinophilic leucocytes has been observed in various other dis- 
eases, but it is scarcely likely that any of these would be mistaken 
for leukaemia, especially if the other blood changes which occur in 
this disease are borne in mind (see p. 78). Eosinophilia has thus 
been noted in bronchial asthma, in certain diseases of the bones, the 
skin, the nervous system, in the helminthiases, in malignant disease, 
in the post-febrile period of many of the acute infectious diseases, in 
gonorrhoea, etc. In diminished numbers the eosinophilic cells are 
found during the process of digestion, in pneumonia, in the course of 
most of the acute infectious diseases, following castration, etc. 

6. Basophilic Leucocytes. — These are only exceptionally seen 
in normal blood, although they are said to be uniformly present to 
the extent of about 0.5 per cent. The granulations, the. y- and 3- 
granulations of Ehrlich, appear to be the same, as those observed in 
the so-called mast-cells found in connective tissue especially. The 
same term has hence been applied to this variety in the blood. The 
individual granules vary somewhat in size and distribution, and are 
characterized by their affinity for the basic dyes. They do not take 
on a pure color, however, but stain metachromatically. With cresyl- 
violet R for example they are colored almost a pure brown. The 
nucleus, moreover, is stained with great difficulty. In specimens 
stained with the tri-acid stain the granules are colorless and the cells 
hence appear as light polynuclear formations, which are apparently 
devoid of granulations. 

An increase in the number of mast-cells is almost exclusively ob- 
served in myelogenous leukaemia, and hence of great diagnostic im- 
portance. This increase is constant and absolute, and may even 
exceed the increase of the eosinophilic leucocytes. 

Neusser's Perinuclear Basophilic Granules. — A few years ago 
Neusser drew attention to the fact that basophilic granules are not 
infrequently seen arranged about the nuclei of the mononuclear and 
polynuclear leucocytes. The presence of these granules he, as well 
as Kolisch, regarded as characteristic of the so-called uric-acid dia- 
thesis. As tubercular disease, moreover, is usually not seen in such 
cases Neusser regards their presence in cases of phthisis as a 
favorable symptom. Futcher on the other hand was unable to con- 
firm these observations, and my own observations are likewise opposed 
to those of Neusser. I was able to demonstrate their presence both 
in health and disease in almost every case, and was even led to the 
conclusion that their absence in a supposedly healthy individual may 



70 THE BLOOD. 

be regarded as presumptive evidence of the existence of some morbid 
process. Whether this will be borne out by further investigation 
remains to be seen. But it appears to be certain that in malignant 
disease the granules are either absent, or present in greatly diminished 
numbers. In two cases of gastric ulcer, and in one of acute gonor- 
rhoea, however, I was likewise unable to find them. 

In suitably stained specimens the granules appear as greenish 
black or entirely black little dots, which are irregularly scattered 
over the surface of the nucleus. Their size varies considerably. 
Specimens are thus encountered in which the granules are as fine as 
ordinary neutrophilic granules, while others are much larger, and in 
some cases droplets may even be seen, which nearly cover the entire 
nucleus. They may be found in all the forms of leucocytes described, 
but are most numerous in the polymorphonuclear and small mono- 
nuclear cells. 

Ehrlich has recently expressed the view that these granules are 
artefacts, and states that they are only exceptionally observed, w T hen 
strictly pure solutions, made from the crystalline dyes of the Actien- 
gesellsehaft fur Anilinfarbstoffe in Berlin, are used. Whether this 
view is correct I am not prepared to say, as my own examinations 
were made with the Grubler stains. A relation between their pres- 
ence and the elimination of uric acid or xanthin bases does not exist. 

7. Neutrophilic Myelocytes. — These are essentially large 
mononuclear leucocytes, the protoplasm of which contains more or 
less numerous neutrophilic granules. Their size, hosvever, is subject 
to considerable variation. On the one hand they may be larger than 
all other elements in the blood, while others are observed which are 
scarcely larger than an ordinary red corpuscle. The nucleus is 
large, usually centrally located, and possesses only a feeble affinity 
for dyes. Unlike the polynuclear neutrophilic leucocytes they are 
never amoeboid. 

According to the school which regards the polynuclear neutrophilic 
leucocytes as the mature forms of the lymphocytes, the neutrophilic 
myelocytes represent an arrested or perverted form of development of 
the large mononuclear leucocytes. Ehrlich, on the other hand, re- 
gards the neutrophilic myelocyte as the bone marrow-cell proper, 
and as the young form of the polynuclear neutrophilic leucocyte. 

Under normal conditions they are never found in the blood, and 
Ehrlich teaches that their presence in considerable numbers may be 
regarded as indicating the existence of myelogenous leukaemia. In 
smaller numbers they have been found in a case of lymphosarcoma 
with metastases in the bone marrow ; further, in severe posthemor- 
rhagic anaemia, in a case of poisoning with mercury, in the pseudo- 
leukemia of infants, in torpid scrofula, and, what is especially im- 
portant, in some of the acute infectious diseases. Engel thus found 



MICROSCOPIC EXAMINATION OF THE BLOOD. 71 

that in diphtheria, occurring in children, myelocytes can often be 
demonstrated in the blood, and that a high percentage, viz, 3.6 to 
16.4 of the total leucocytes, is only observed in severe cases and ren- 
ders the prognosis unfavorable. In light cases they are not often 
seen, and when present occur only in small numbers. In pneumonia 
myelocytes are either absent, or present only in small numbers, at 
the beginning of the disease, while at the time of the crisis or imme- 
diately thereafter they become more numerous, and in some cases 
may number 12 per cent, of all neutrophilic cells. 

8. Eosinophilic Myelocytes. — These represent the eosino- 
philic analogon of the form just described. Their size may also 
vary very much, and specimens may be met with which are a great 
deal larger than the poly nuclear variety. According to Ehrlich they 
are likewise formed in the bone-marrow, and represent an earlier 
stage in the development of the polynuclear eosinophilic leucocyte. 
Their presence is largely confined to the blood of myelogenous leu- 
kaemia and the pseudo-leukaemia of infants. Mendel found them in 
one case of myxoedema, and Tiirck reports that they are occasionally 
seen in some of the infectious diseases. 

9. Small Neutrophilic Pseudo- lymphocytes. — These bodies, 
according to Ehrlich, are produced by direct division of the polynu- 
clear neutrophilic leucocytes. They are about as large as the small 
lymphocytes, and provided with a single deeply staining nucleus. 
The narrow zone of protoplasm which surrounds the nucleus con- 
tains neutrophilic granules. They may be distinguished from the 
small forms of myelocytes by the greater intensity with which the 
nucleus takes up the nuclear dyes, and the smaller amount of proto- 
plasm. Ehrlich states that he first saw these bodies in a case of 
hemorrhagic small-pox, but that they are also found in fresh pleural 
effusions. He suggests that their study may be of importance in 
deciding the origin of the transitory hyperleucocytoses, which ac- 
cording to some are due to a destruction of leucocytes, and accord- 
ing to others to an altered distribution. 

10. Irritation Forms. — These are mononuclear, non-granular 
cells, the protoplasm of which is stained a rich brown by the tri-acid 
mixture. The nucleus is round, often exccntrically located, and colored 
a bluish-green. The smallest forms are somewhat larger than the 
lymphocytes. According to Tiirck, who first described these cells 
they are met with under the same conditions as the myelocytes. 
Possibly they represent an early stage in the development o^ the 
nucleated red corpuscles. 

In addition to the above, still other forms of leucocytes have been 
described, especially in leuksemic blood, but so little is known of 
these that is at all definite 4 that it is unnecessary to enter into their 
description at this place. 



72 THE BLOOD. 

Variations in the Number of the Leucocytes. — While the num- 
ber of red corpuscles is subject to very slight variations under physi- 
ologic conditions, that of the leucocytes varies within fairly wide 
limits, being influenced by the age and sex of the individual, preg- 
nancy, the process of digestion, the blood-vessel from which the 
specimen is taken, etc. 

According to Osier, the number of leucocytes per cbmm. of 
blood, obtained from the finger or the ear, normally varies between 
5,000 and 7,000, so that taking 5,000,000 as the average number of 
red corpuscles per cbmm., the ratio between the two would vary be- 
tween 1:714 and 1 : 1,000. But, as Cabot points out, the actual num- 
ber may be still lower than 5,000 and higher than 7,000 without 
there being symptoms of definite illness. Generally speaking, lower 
figures are met with in persons who are somewhat ill-nourished, 
while higher figures are encountered in persons of special vigor and 
good nutrition. Before concluding then that in a given case the 
number of leucocytes is below or above the normal, an idea should, 
if possible, be formed of what constitutes the normal for that par- 
ticular individual. It would hence be better to extend the normal 
limits to 3,000 on the one hand and 10,000 on the other. 

An increase in the number of leucocytes, to which condition the 
term leucocytosis was first applied by Yirchow, is met with under 
both physiologic and pathologic conditions. As Goldscheider rightly 
suggests, it would be better, however, to restrict the term leucocy- 
tosis to indicate the number of leucocytes in a general way, and to 
speak of an increase in their number as hyperleucocytosis and of a dim- 
inution in their number as hypoleucocytosis. According to Ehrlich, 
furthermore, it is necessary to distinguish between active and passive 
hyperleucocytosis, meaning by active hyperleucocytosis that form in 
which the increase in the number of the leucocytes principally 
affects the phagocytic elements, viz, the polynuclear leucocytes, 
while the mononuclear elements only are increased in the passive 
form. 

The active hyperleucocytoses Ehrlich further subdivides into the 
following groups : 

1. The polynuclear hyperleucocytoses. 

a. Polynuclear neutrophilic hyperleucocytosis. 

b. Polynuclear eosinophilic hyperleucocytosis. 

2. The mixed hyperleucocytoses, in which the granule-bearing 
mononuclear elements take part — Myelsemia. 

Polynuclear Neutrophilic Hyperleucocytosis. — In this form of 
hyperleucocytosis, as the term indicates, the increase in the number 
of the leucocytes principally affects the polynuclear neutrophilic 
elements. Exceptionally it may be associated with a polynuclear 
eosinophilic hyperleucocytosis, as well as with a lymphocytosis, but 



MICROSCOPIC EXAMINATION OF THE BLOOD. 73 

as a general rule both eosinophilic leucocytes and lymphocytes are 
much diminished. This diminution, moreover, may not only be 
relative, but even absolute. 

Under this heading the following forms may be considered : 

Physiologic Hyperleucocytosis. — An increase in the number of 
leucocytes, occurring in health, is noted in children, during the 
process of digestion, in pregnancy, following the use of cold baths, 
after severe muscular exercise, etc. 

In infancy a hyperleucocytosis is quite constantly observed, and 
according to Hayem most pronounced during the first eighty hours 
of life, when about 18,000 leucocytes are found, on an average, in 
the cbmm. of blood. This number, however, soon diminishes, and 
during the first month about 8,000 leucocytes may be regarded as 
the normal. In children, aged from several months up to the first 
year, this figure further drops to about 6,000. Owing to the inten- 
sity with which the blood of infants generally reacts to all manner 
of stimuli, however, it is difficult to set down definite figures to ex- 
press the normal. It is thus not uncommon to observe a hyperleu- 
cocytosis corresponding to the first months of life, even as late as the 
first and second year, in feebly developed children, but which, in 
other respects, may be quite healthy. The process of digestion, 
moreover, as will be shown later, very materially influences the de- 
gree of leucocytosis, so that at this time of life one should be very 
careful in drawing inferences from the blood count alone as to the 
existence of diseases. 

Associated with an absolute increase in the number of the poly- 
nuclear neutrophilic leucocytes we find in the leucocytoses of infants 
quite constantly also a relative lymphocytosis. 

An idea of the marked increase in the number of the leucocytes, 
occurring during the process of digestion, constituting the physio- 
logic digestive leucocytosis of Virchow, may be formed from the ac- 
companying diagram (Fig. 14). It is especially pronounced after a 
previous period of fasting, and after a meal rich in proteids. Oc- 
casionally it is not seen, even in health, but such cases are excep- 
tional. In infants the highest grades are observed, and Cabot cites a 
case, reported by Schiif, in which 19,500 leucocytes were counted 
one hour after birth, 27,625 after the first meal, and 36,001) after the 
fourth meal. 

In diseased conditions, and notably in gastro-intestinal diseases, 
this form of hyperleucocytosis is frequently absent. This is notably 
the case in carcinoma of the stomach, and for a time it was thought 
that the absence of digestive hyperleucocytosis could be regarded as 
a valuable symptom in the differential diagnosis between carcinoma 
and other diseases of the stomach. Unfortunately further investiga- 
tions have shown that cases of cancer may occur on the one hand, in 



74 



THE BLOOD. 



which digestive hyperleucocytosis does occur, while, on the other, 
it may be absent in other diseases, both functional and organic. 
The question of digestive hyperleucocytosis is, however, nevertheless 

Fig. 14. 

Red corpuscles in 1 cbmm. of blood. 



[ill. 
5,6 
5,5 






8 


A.M. 

10 


12 


2 


4 


P.M. 

6 8 


10 


12 


2 


A.M. 

4 6 


8 


























































/ 






















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/ 








5,3 

5,2 
5,1 
6,0 
















\ 































































































































































































































































































Hb. in 1 cbmm. of blood. 



n 140 


































































































































































































































/ 






















0,130 














































































\ 












































0,125 


















S 


^v 




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Leucocytes in 1 cbmm. of blood. 



















































































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( 


















) 


k --- 


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\ 


s 






























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S 


i 


























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\ 
























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! 












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8000 
7500 
7000 
6500 
6000 
5500 
5000 



Showing the diurnal variations in the number of red corpuscles, the amount of haemoglobin, and 
the number of leucocytes. (Taken from Reixert.) 



a most interesting one and calls for further investigation. In its 
study certain precautions must be observed : 

a. The first blood count should be made after the patient has 
fasted for about seventeen hours. 



MICROSCOPIC EXAMINATION OF THE BLOOD. 75 

b. After this period he receives a test-meal, consisting of from 200 
to 1,000 c.c. of milk, and of one or two eggs, the amount varying 
with the condition of the patient. 

c. Farther blood counts are made one, two, and three hours later. 

d. The existence of a digestive hyperleucocytosis should only be 
regarded as proven, if an increase of at least 1,500 cells occurs, pro- 
viding that maximal amounts of food have been taken. If smaller 
amounts have been given an increase of 100 cells is sufficient to es- 
tablish its existence, provided that the same result is observed on 
repeated examination. 

In the digestive hyperleucocytoses the increase in the number of 
the leucocytes not only affects the polynuclear neutrophilic elements, 
but also the lymphocytes, while the eosinophilic leucocytes are, rela- 
tively at least, much diminished. 

A very marked hyperleucocytosis is also frequently noted after a 
cold bath. According to Thayer this may even amount to 284.6 
per cent. In twenty cases of typhoid fever he found 7,724 leuco- 
cytes, on an average, before, and 13,170 after the usual Brand bath. 
In his own person, while in health, on one occasion the leucocytes, 
which numbered 3,250 before the bath, rose to 12,500 twenty min- 
utes later. 

A prolonged cold bath on the other hand diminishes their num- 
ber. Hot baths have exactly the opposite effect, viz, those of short 
duration produce a decrease, those of long duration an increase. 

Violent muscular exercise, as well as massage, likewise calls forth 
a temporary hyperleucocytosis. 

In all these cases the increase affects both lymphocytes and the 
polymorpho-nuclear leucocytes. 

The physiologic hyperleucocytosis observed in pregnancy is par- 
ticularly marked during the last five months, and appears to occur 
quite constantly in primiparse, while in multiparas exceptions are 
common. In an analysis of thirty-one cases Rieder noted a hyper- 
leucocytosis in twenty, the number of leucocytes varying between 
10,000 and 16,000, with an average of 13,000 per cbmm. This in- 
crease in the number of the leucocytes continues for a variable 
period after parturition and is apparently connected with lactation. 
It is especially interesting to note that a digestive hyperleucocytosis 
docs not occur, while that referable to pregnancy exists, and it is 
quite likely, as Cabot suggests, that this form is in reality a pro- 
longed digestive hyperleucocytosis. The increase affects both lym- 
phocytes and the polynuclear neutrophilic leucocytes. 

Pathologic Hyperleucocytosis. — In diseases an increase in the 
number of the polynuclear neutrophilic leucocytes is very frequently 
observed, and often a matter of great importance in differential diag- 
nosis. 



76 THE BLOOD. 

In the acute infectious diseases hyperleucocytosis is the rule. Gen- 
erally speaking, the increase in the number of the leucocytes is here 
directly proportionate to the intensity of the infection and the power 
of resistance on the part of the individual patient. It may thus 
happen that no hyperleucocytosis occurs at all, when the infection is 
extremely virulent, and the power of resistance practically nil, in 
consequence of preexisting disease, or similar influences, even though 
the disease is one in which hyperleucocytosis generally occurs. 
This is seen especially well in pneumonia, where death almost invari- 
ably occurs, when a hyperleucocytosis does not develop, unless in- 
deed the infection has been so mild as not to call forth an increased 
invasion of leucocytes. The development of a well-marked hyper- 
leucocytosis in diseases, in which this is the rule is no guarantee, 
however, that the patient will recover, although his chances are 
certainly much better. 

In pneumonia the increase in the number of the leucocytes is 
usually marked. According to Cabot it amounts on an average to 
about 24,000 beyond the normal. The hyperleucocytosis sets in 
quite early and persists until the time of the crisis, when it rapidly 
disappears. When the disease terminates by lysis the return to the 
normal is more gradual. A pseudo-crisis is not accompanied by a 
fall in the number of the leucocytes. When resolution is delayed, 
or complications occur the hyperleucocytosis persists. 

In erysipelas, as in pneumonia, the leucocytosis is generally pro- 
portionate to the intensity of the morbid process, and also terminates 
by crisis. The increase in the number of the leucocytes, according 
to Eieder, amounts to about 15,000 beyond the normal. 

In diphtheria a well-marked increase is the rule, and with the ex- 
ception of very mild or extremely severe cases, of constant occur- 
rence. It is interesting to note that barring a temporary diminution 
immediately after the injection the leucocytosis is in no wise influ- 
enced by the antitoxin treatment. 

In septic conditions of whatever origin, hyperleucocytosis is of 
constant occurrence, unless the infection is very mild or very severe. 
Thus, as in pneumonia and diphtheria, the absence of hyperleuco- 
cytosis may usually be regarded as a symptom of grave prognostic 
significance. The degree of increase may vary widely and is always 
directly proportionate to the extent and degree of the inflammatory 
reaction. In suspected cases a careful examination of the blood 
should always be made. It is equally important in such cases as the 
examination of the sputum in suspected cases of phthisis or of the 
tonsillar coating in suspected cases of diphtheria. 

In acute articular rheumatism the degree of hyperleucocytosis is 
proportionate to the severity of the attack. The average increase be- 
yond the normal, according to Cabot, amounts to about 16,800 cells. 



MICROSCOPIC EXAMINATION OF THE BLOOD. 77 

In scarlatina an increase in the number of the leucocytes may be 
observed as early as the sixth day before the appearance of the rash. 
The maximum, an increase of from 10,000 to 25,000 beyond the 
normal is usually noted on the second or third day after the appear- 
ance of the eruption. 

In small-pox a hyperleucocytosis is only observed in the severer 
cases, and at a time when the formation of pustules occurs. In the 
milder forms no increase occurs. 

In tubercular disease hyperleucocytosis is only observed when 
secondary infection with pus-organisms has taken place, Avhile in 
pure cases the number remains normal. But, as the chances for a 
secondary infection are more favorable in some parts of the body than 
in others, such as the lungs and kidneys, hyperleucocytosis is more 
commonly present than absent, when these parts are involved. 

It is thus seen that a hyperleucocytosis of greater or less degree 
occurs in the great majority of the infectious diseases, and may be 
regarded as the rule. There are, however, a number of very inter- 
esting and important exceptions. In uncomplicated cases of typhoid 
fever, and in measles no hyperleucocytosis occurs and the number of 
the leucocytes may indeed be diminished. The importance of this 
fact from the standpoint of differential diagnosis is self-evident. 

As regards the other forms of leucocytes in the acute infectious 
diseases, it is known, that with a return to the normal of the poly- 
nuclear neutrophilic elements a temporary increase in the number of 
the eosinophiles often occurs. With the decline of the hyperleucocy- 
tosis, moreover, mononuclear neutrophilic leucocytes and irritation 
forms frequently appear in small numbers. The lymphocytes remain 
practically uninfluenced. 

The toxic hyperleucocytoses likewise belong to this order. An 
increase in the number of the polynuclear neutrophilic elements is 
thus observed in cases of poisoning with potassium chlorate, the de- 
rivatives of phenylhydrazin, pyrodin, phenacetin, arseniuretted hy- 
drogen, sulphonal, quinine, illuminating gas, as also following the 
prolonged administration of chloroform and ether. 

Under this heading Cabot also groups the hyperleucocytoses which 
may be observed in certain cases of rickets, gout, acute yellow 
atrophy, advanced cirrhosis of the liver (especially, when associated 
with jaundice), acute gastro-intestinal disorders (ptomains), acute and 
chronic nephritis, hydronephrosis, following the injection of tuber- 
culin, thyroid extract and even normal salt solution, as also after the 
ingestion of salicylates. 

A hyperleucocytosis affecting the polynuclear neutrophilic ele- 
ments is further observed in various forms of acute and chronic an se- 
mia. This is especially marked after hemorrhages referable to 
traumatism, where the number oi' leucocytes may increase to 30,000 



78 THE BLOOD. 

and even more. Generally speaking, the degree of hyperleucocytosis 
is here proportionate to the amount of blood lost and the recuperative 
power of the individual. 

In the primary forms of anaemia, if we except the myelogenous 
type of leuksemia, where an absolute increase is associated with a 
relative decrease, hyperleucocytosis referable to the polynuclear neu- 
trophilic leucocytes is not met with in uncomplicated cases. In the 
secondary anaemias, on the other hand, though usually of moderate 
degree, it is quite common. 

We finally recognize a cachectic hyperleucocytosis which is ob- 
served in malignant disease, phthisis, etc. 

Polynuclear Eosinophilic Hyperleucocytosis (Eosinophilia). — 
Aside from the increase of the eosinophilic leucocytes which may be 
observed in children under normal conditions, eosinophilia is essen- 
tially a pathologic phenomenon. 

While a relative increase of the eosinophilic leucocytes may or 
may not occur in myelogenous leukaemia, the absolute number is 
always increased in uncomplicated cases. Where septic processes 
supervene, however, this increase may not occur, and the absolute, 
as well as the relative number, is then usually much diminished. 
For a while eosinophilia was thought to be pathognomonic of this 
form of leukaemia. But we now know that a polynuclear eosino- 
philic hyperleucocytosis also occurs in other diseases. Its constant 
occurrence in myelogenous leukaemia should nevertheless be borne in 
mind, and the diagnosis discarded, whenever such an increase cannot 
be demonstrated. 

In bronchial asthma an increase of the eosinophilic leucocytes is 
quite constantly observed about the time of the paroxysm, and may 
amount to from 10 to 20 per cent. Its occurrence is of value in 
differential diagnosis, as renal and cardiac asthma are not associated 
with eosinophilia. 

In many diseases of the skin, notably in pemphigus, prurigo, 
psoriasis, and urticaria a marked eosinophilia may be observed, which 
in some cases may amount to 60 per cent, of the total leucocytes. 
Its degree is apparently proportionate to the amount of tissue in- 
volved. 

Especially interesting, furthermore, is the increase of the eosino- 
philic leucocytes which is observed in association with the presence 
of intestinal parasites. According to Leichtenstern its occurrence is 
especially pronounced in those cases, in which Charcot-Leyden crys- 
tals are numerous in the feces. The greatest increase is found in 
ankylostomiasis, where 72 per cent, were counted in one case. In 
the presence of oxyurides Buckler found 16 per cent. Nineteen 
per cent, were counted in association with ascarides, and Leichten- 
stern reports one case of taenia mediocanellata with 34 per cent. 



MICBOSCOPIC EXAMINATION OF THE BLOOD. 79 

Of great interest and practical importance is the observation, first 
made by T. R. Brown, at the Johns Hopkins Hospital, that trichi- 
nosis in its acute stage, at least, is associated with a very remarkable in- 
crease in the number of the eosinophilic leucocytes. In the four cases 
reported by him the eosinophiles reached 68.2 per cent, of the total 
leucocytes, in the first ; in the second, 42.8 per cent.; in the third, 
49 per cent., and in the fourth, 48 per cent., while the total number 
of leucocytes per cbmm. was 35,000, 13,000, 17,000 and 18,000 re- 
spectively. As the disease is apparently much more common in our 
country than is generally supposed, and as the diagnosis, except in 
the most marked cases or in the epidemic form, is impossible with- 
out an examination of the blood, it is highly advisable to make such 
examinations in febrile conditions of doubtful origin, as well as in 
cases with indefinite intestinal and muscular symptoms. Whenever 
an eosinophilia of marked grade should be discovered under such 
conditions a small bit of muscle tissue should be excised and exam- 
ined for trichinae directly. 

As I have pointed out before, the eosinophilic leucocytes are rela- 
tively diminished, and may disappear altogether in the great major- 
ity of the acute infectious diseases, with the exception of scarlatina 
perhaps, while the hyperleucocytosis, referable to the polynuclear 
neutrophilic cells, exists. In the post-febrile period, however, the 
upper limit of the normal and even a well-marked eosinophilia is 
often observed. Tiirck thus found an epicritic eosinophilia of 5.67 
(430 absolute) in a case of pneumonia, and after an attack of acute 
articular rheumatism 9.37 per cent. (970 absolute). Zappert re- 
ports a case of malaria in which on the day following the last attack 
20.34 per cent. (1,486 absolute) were found. 

Similar observations have been made after the injection of tuber- 
culin, where a febrile reaction has taken place. In one case, reported 
by Grawitz, the eosinophilia reached its highest point, viz, 41,000 
per cbmm., three weeks after the injections had been stopped. 

In malignant disease eosinophilia apparently only occurs in a rela- 
tively small percentage of cases, and when present is usually of 
moderate grade, i. e., not exceeding seven to ten per cent. Occa- 
sionally, however, the increase is most remarkable. Reinbach thus 
cites a case of lymphosarcoma of the neck with metastases in the 
bone marrow, in which 60,000 eosinophilic leucocytes were counted 
on one occasion. 

The eosinophilia which is observed in certain cases of gonorrhoea 
has of late been carefully studied by O wings in my laboratory. From 
an analysis of his forty-two cases it appears that with an extension 
of the inflammatory process to the posterior urethra the number of 
cases increases in which an increased percentage o( eosinophiles is 
found in the blood, and in eases of prostatitis eosinophilia is the rule. 



80 THE BLOOD. 

During the first week of the disease the blood is apparently always 
normal. In the second and third weeks it is normal in only 33 per 
cent, of all cases, and after two months' duration an increased number 
is still observed in 40 per cent. Occasionally the eosinophilia is as- 
sociated with an increase of the polynuclear neutrophilic leucocytes. 

After extirpation, as also in chronic tumors of the spleen, eosino- 
philia has been repeatedly observed. Midler and Rieder report three 
cases of tumor, referable to congenital syphilis, hepatic cirrhosis, and 
neoplasm of the cranial cavity, in which 12.3, 7, and 6.5 per cent, 
respectively were found. After extirpation of the organ an eosino- 
philia is not immediately observed, but only develops after many 
months, and is of moderate grade. 

An eosinophilia referable to drugs has finally been described, but 
has attracted but little attention. Two cases are reported by v. 
Noorden, who observed an increase of the eosinophiles to 9 per cent. 
Both were cases of chlorosis, and in both the eosinophilia followed 
the internal administration of camphor. Similar observations have 
been made in animals, after poisoning with carbon dioxide. 

Mixed Hyperleucocytosis. — This term is applied by Ehrlich to 
that form of active hyperleucocytosis, in the production of which 
granule-bearing mononuclear leucocytes also play a part. This con- 
dition is practically only found in one disease, viz, the myelogenous 
form of leukaemia. Mononuclear neutrophilic leucocytes, it is true, 
are also found in other diseases, which are associated with hyper- 
leucocytosis, but the quotum which they furnish toward the general 
increase is there so slight, probably never amounting to more than 
1,000 per cbmm., as scarcely to affect the total number. 

In former years a sharp line of distinction between simple hyper- 
leucocytosis and myelogenous leukaemia did not exist, and leukcemia 
was essentially regarded as a hyperleucocytosis, in which the ratio 
between the white and red corpuscles exceeded a definite proportion, 
Avhich was generally placed as 1 : 50. As a matter of fact there is 
probably no other disease, in which so great an increase in the num- 
ber of the leucocytes is observed, and even at the present day the 
diagnosis of leukaemia is practically proven, when such a proportion 
can be shown to exist. The absolute number of the leucocytes may 
actually exceed that of the red corpuscles. In his series of thirty 
cases Cabot found 438,000 on an average per cbmm. His highest 
ratio was 1 : 2, and the lowest 1 : 37. There are exceptional cases 
of myelogenous leukaemia, however, in which the hyperleucocytosis 
is not so extreme, and in which the ratio may not exceed 1 : 200. 
While the enumeration of the total number of leucocytes is thus of 
unquestionable value in the diagnosis of myelogenous leukaemia, it 
alone is not the determining factor. We must know on the other 
hand what particular elements contribute toward the total increase. 



MICROSCOPIC EXAMINATION OF THE BLOOD. 81 

In the lymphatic form of leukaemia, as will be shown more specifi- 
cally later on, the hyperleucocytosis is thus dependent upon an in- 
crease of the non-granular mononuclear elements. In contradistinc- 
tion to this form the hyperleucocytosis of myelogenous leukaemia is 
essentially a hyperleucocytosis referable to leucocytes which are not 
seen in the blood under normal conditions, viz, the mononuclear 
neutrophilic leucocytes. As these elements are the bone-marrow 
leucocytes proper we have in myelogenous leukaemia a true myelcemia. 
The number of neutrophilic mononuclear leucocytes, which is met 
with in such cases is often very remarkable, and the appearance of 
from 50,000 to 100,000 in the cbmm. is by no means exceptional. In 
eighteen cases reported by Cabot, the average percentage was 37.7 
corresponding to a total number of 162,000 per cbmm. ! 

In addition to the myelocytes the eosinophilic mononuclear leuco- 
cytes, which normally are likewise only found in the bone-marrow, 
also appear in the blood, and constitute the majority of the eosinoph- 
ilic cells seen in this form of leukaemia. The polynuclear eosinoph- 
ilic elements are at the same time absolutely increased, but their 
relative percentage may be normal. This absolute increase is so in- 
variable in uncomplicated cases, that we must regard it as one of the 
constant symptoms of the disease. Important, further, is the in- 
variable increase of the mast-cells, which is absolute. As a general 
rule their number is about one-half that of the eosinophils, but oc- 
casionally they are equally as numerous, and exceptionally even 
more so. Ehrlich holds that from a diagnostic point of view they 
are perhaps even more important than the eosinophilic leucocytes for 
the reason that in contradistinction to these we know of no other 
condition in which the mast-cells are materially increased. 

The polynuclear neutrophilic cells and the lymphocytes, although 
absolutely increased, are relatively much diminished. Of the latter 
only 7.6 per cent, are thus found on an average, and of the former 
49.2 per cent., as compared with 20 to 30 and 60 to 70 respectively. 

The occurrence of dwarfed forms of both eosinophilic and neu- 
trophilic polynuclear and mononuclear leucocytes in leukemic blood 
has already been mentioned. Occasionally cells in which mitoses 
can be observed are also seen, but are of no special interest. 

The above considerations have reference to uncomplicated cases of 
leukaemia. Where septic complications occur the blood condition 
may undergo great changes. Thus, in proportion to the degree of 
infection the myelaemic picture gradually disappears, and is replaced 
by that seen in simple septic conditions. The polynuclear neu- 
trophilic leucocytes may then increase to 90 per cent, and even 
higher. 

A very rare complication is further described by Ehrlich in which 
in the terminal stage of the disease the bone-marrow apparently 



82 THE BLOOD. 

loses its power of producing neutrophilic material, and where as 
the result non-granular myelocytes, so to speak, appear in the blood. 
In one case of this kind which he reports the great majority of the 
mononuclear elements, which numbered 70 per cent, of the total 
number of the leucocytes, were entirely free from neutrophilic 
granules. 

Passive Hyperleucocytosis (Lymphocytosis). — Lymphocytosis 
is obseryed whenever an increased circulation of lymph occurs in 
more or less extensive lymphatic districts, the lymphocytes being 
mechanically washed into the blood current. In a mild form it is 
thus seen in certain forms of the so-called physiologic hyperleu- 
cocytosis (see p. 73), where the increase in the number of the lymph- 
ocytes is associated with a corresponding increase of the polynuclear 
neutrophilic elements. To a more marked degree it is seen in vari- 
ous diseases of the gastro-intestinal tract in infants. A well pro- 
nounced lyniphaemia is further observed in whooping-cough, where an 
increase to four times the normal number may occur during the con- 
vulsive stage. The polynuclear cells are at the same time increased, 
but not to the same degree. 

Following the injection of tuberculin lymphocytosis is occasionally 
observed, and "Waldstein claims to have produced a marked increase 
by hypodermic injections of pilocarpin. 

Important from a diagnostic standpoint is the fact that in malig- 
nant lymphoma lymphocytosis is constantly observed, and may be of 
very high grade. 

In contradistinction to the active forms of hyperleucocytosis, 
lymphocytosis is thus only observed in a comparatively small num- 
ber of diseases, and is usually not of high grade. There is really 
one disease only, if we except malignant lymphoma, in which an ac- 
tual flooding of the blood with lymphocytes occurs — viz, lymphatic 
leukaemia. As in myelogenous leukaemia the total number of the 
leucocytes is here also very much increased, but never to the same 
degree. The average proportion between the white and red corpus- 
cles thus scarcely ever exceeds 1 : 40, corresponding to 141,000 leuco- 
cytes per cbmm. The highest count in Cabot's series was 220,000, and 
the lowest only 40,000. Of this number about 90 per cent, are 
lymphocytes. Myelocytes and eosinophilic leucocytes are scanty. 
When septic processes develop in such cases, the total number of the 
leucocytes, as in the myelogenous form of leukaemia likewise under- 
goes a considerable diminution, but the lymphocytes still remain 
relatively increased. In one case of Cabot's, where, as the result of 
septicaemia the total number of leucocytes fell to 471 per cbmm. the 
percentage of lymphocytes still was 94.7. 

Hypoleucocytosis (Leukopenia). — In the foregoing pages it has 
repeatedly been pointed out that a qualitative diminution in the num- 



MICROSCOPIC EXAMINATION OF THE BLOOD. 83 

ber of the leucocytes may occur under the most diverse conditions. A 
quantitative diminution on the other hand, viz, a diminution of the 
total number of leucocytes is only observed in comparatively few 
diseases. 

Most important from a diagnostic standpoint is the hypoleucocyto- 
sis, which is so commonly seen in uncomplicated cases of typhoid 
fever, as to constitute one of the most important symptoms of the 
disease. Exceptions to this rule occur, but are not common. In the 
initial stage of the disease owing to a concentration of the blood, re- 
sulting from starvation and diarrhoea, higher counts are sometimes 
observed, but as the disease progresses the number soon diminishes, 
and in the later weeks is practically always well below the normal. 
Not uncommonly less than 2,000 are counted in the cbmm., and in 
some instances even less than 1,000 are seen. Whenever an increase 
in the number of the leucocytes is observed in a suspected case of typhoid 
fever it is even more than probable that some complication exists, or that 
the diagnosis is wrong. 

Uncomplicated cases of tuberculosis are likewise not associated 
with hyperleucocytosis. But as it is very much more common to 
meet with cases in which secondary infection has taken place, lead- 
ing to hyperleucocytosis, its absence is often of value in differential 
diagnosis. 

Important, furthermore, is the hypoleucocytosis of measles, which 
is commonly observed in uncomplicated cases, and may aid in distin- 
guishing the disease from scarlatina. 

In severe cases of anaemia the occurrence of hypoleucocytosis is 
always a grave symptom, as it indicates an inability on the part of 
the bone-marrow to produce a sufficient number of blood-corpuscles. 
Ehrlich supposes that in such cases the fatty marrow of the long 
bones is not transformed into red marrow, and has actually observed 
two cases, in which the correctness of this supposition could be de- 
monstrated at the post-mortem table. 

While the hypoleucocytosis in the diseases mentioned is rarely 
extreme, most extraordinary instances of leukopenia are at times 
encountered. Ehrlich thus cites the case of a well-built young man, 
in whom brief epileptiform seizures occurred, and in one of which 
the patient died. The post-mortem examination was entirely nega- 
tive. During the three days of observation, preceding death, two 
examinations of the blood were made. On the one day not a single 
leucocyte could be demonstrated in ten blood films, and on the second 
day but one was found in the same number of specimens. 

The Drying and Staining of Blood. 

In order to obtain the best results cover-glasses of the finest grade, 
measuring not more than 0.08 to 0.10 mm. in thickness are metis- 



's 



84 



THE BLOOD. 



pensable. They should be cleansed with special care. To this end 
Ehrlich's method may be employed : The individual glasses are first 
placed in a tray with ether for half an hour, care being taken that 
they are well separated from one another. They are then dried 
with fine linen, or so-called Joseph's-paper, placed in absolute alcohol 
for a few minutes, dried again and kept in dust-proof glass dishes, 
when they are ready for use. When once cleansed the cover-glasses 
should only be handled with forceps, as the moisture of the hands is, 

Fig. 15. 




Ehrlich's cover-glass forceps. 

in itself, sufficient to cause post-mortem changes in the red corpus- 
cles. For this purpose specially constructed instruments, such as 
those suggested by Ehrlich will be found most serviceable. One 
cover-glass is grasped with the flat-bladed forceps, provided with a 
sliding lock (Fig. 15) and held in the left hand. The second cover 
is taken up with the other forceps, which should have a light spring 
and need not be provided with a lock (Fig. 16), brought in contact 
with the drop of blood, and then immediately placed upon the first. 
Providing that the glasses are of the proper quality and clean, the drop 

Fig. 16. 




Liusley's cover-glass forceps. 



of blood will spread out in a uniform layer. Ehrlich now recom- 
mends that the top. cover is slid from the lower cover with the 
fingers, by grasping the former tightly and drawing it away in a 
plane parallel to the other. But it seems to me that at this stage 
forceps should also be employed. 

The drop of blood may be obtained from the tip of a finger or the 
lobe of the ear, after careful cleansing with soap and water, and, 
whenever possible, also with alcohol and ether. Under no consider- 



MICROSCOPIC EXAMINATION OF THE BLOOD. 85 

ations should the drop be so large that the top cover floats upon the 
blood. 

The proper spreading of the blood is at the same time the most 
important and the most difficult step in the preparation of dried 
specimens, and requires a considerable amount of experience, as well 
as care. 

After drying in the air the specimens are placed between layers of 
filter paper, and may then be examined at leisure. If for any rea- 
son it is desired to preserve the specimens for a long time, i. e., for 
months or years, it is best to coat the blood films with a thin layer 
of paraffin, which is later dissolved by immersion in toluol. In this 
manner especially valuable and rare specimens may be kept for a 
long time without any danger of spoiling, but even without this 
precaution the blood films will remain unchanged for a long time. 

Before staining it is usually necessary to fix the albuminous 
bodies of the blood. To this end different methods may be em- 
ployed. Immersion in absolute alcohol for from 5 to 30 minutes, or 
in a mixture of equal parts of absolute alcohol and ether for two 
hours is very convenient and furnishes good results. There can be 
no doubt, however, that the finest pictures are obtained, when the 
specimens have been fixed by heat. For ordinary purposes it is only 
necessary to expose the air-dried blood films to a temperature of 
from 100° to 120° C. for from one-half to two minutes, while in spe- 
cial cases a more prolonged exposure, or a higher temperature may 
be required. For fixing by heat Ehrlich recommends the use of the 
so-called Victor-Meyer apparatus in a slightly modified form. This 
is essentially a small copper kettle, covered with a thin plate, which 
is perforated for the reception of the boiling tube. If a small 
amount of toluol is boiled in this kettle for a few minutes the cop- 
per plate is soon heated to a temperature of from 107° to 110° C, and 
retains this temperature sufficiently long for ordinary purposes. In 
the absence of such an instrument a small coal-oil stove, upon which 
a copper plate measuring 40 by 10 cm. is placed, will answer the 
purpose. Upon this plate the line corresponding to the desired tem- 
perature is ascertained by means of a scries of drops of water, tol- 
uol (boiling point at 110° to 112° C), xylol (boiling point 187° to 
140° C), etc., and noting the line at which ebullition occurs. When 
once properly regulated the apparatus, which may be advantageously 
placed in a box, so as to guard against currents of air, will be found 
to furnish a fairly constant temperature. A drying-oven provided 
with a thermostat and thermometer may of course be used tor the 
same purpose. Of late formol has also been much lauded as a fix- 
ing agent, and may be used in connection with the tri-acid stain, 
hematoxylin and eosin, thionin, etc. A 1-per-eent. alcoholic solu- 
tion is employed. This is prepared by diluting one part of formol, 



86 THE BLOOD. 

which is a solution of 40 per cent, of formaldehyde in methyl alco- 
hol and water, with nine times its own volume of water, and one 
part of the resulting solution with nine times its volume of alcohol. 
Fixation is completed in one minute, and for practical purposes it is 
merely necessary to cover the blood film with a few drops of the so- 
lution, which is then drained off and replaced with the staining rea- 
gent directly. 

When fixed according to one of the methods described the dried 
specimen is ready for staining. For this purpose a number of so- 
lutions may be employed, the selection of the special mixture de- 
pending upon the points to be elicited. 

Staining with Ehrlich's Tri-acid Stain. — This method is un- 
questionably one of the most useful and convenient for all practical 
purposes. Great care, however, is necessary in the preparation of 
the stain, and chemically pure dyes are absolutely essential. Ehr- 
lich recommends the crystallized dyes prepared by the Actiengesell- 
schaft fur Anilinfarbstoffe in Berlin. In my experience I have 
found the well-known preparations of Dr. G. Griibler & Co. in Leipzig 
entirely satisfactory. Saturated aqueous solutions of orange-G, acid 
fuchsin and methyl-green are first prepared, and allowed to clear by 
standing for at least one week. The various ingredients are then mixed 
in the order given below, using one and the same measuring glass. 
After the addition of the methyl-green solution, the mixture should 
be thoroughly agitated, until the final ingredients have been added. 
When completed trial specimens are stained in order to ascertain 
whether the requisite amounts of acid fuchsin and methyl-green have 
been added. Should the neutrophilic granules be insufficiently stained 
a few drops more of the acid fuchsin or methyl-green, or of both, are 
added, as the case may be. 

Orange-G solution 
Acid Fuchsin solution 

Distilled water 

Alcohol ...... 

Methyl-green solution 

Alcohol 

Glycerine ...... 

The solution is ready for use at once and improves with age. 1 
If properly prepared the nuclei of the leucocytes will be stained 
greenish, the eosinophilic granules a copper color, and the neutro- 
philic granules violet. The nuclei of the basophilic leucocytes are 
stained a pale green, while the surrounding protoplasm remains 
colorless. Ordinarily the red corpuscles are stained orange, but in 
cases of chronic anaemia individual corpuscles may be seen which do 

1 A reliable tri-acid stain is sold by Messrs. Hynson and Westcott, of Baltimore, 
Md. 





. 13-14 


c.c 




. 6- 7 


c.c. 




. 15 


c.c. 




. 15 


c.c. 




. 12.5 


c.c. 




. 10 


c.c. 




. 10 


c.c. 



MICROSCOPIC EXAMINATION OF THE BLOOD. 87 

not take on a pure orange tint, but a mixed tint, in which the 
fuchsin predominates to a greater or less degree. This altered sus- 
ceptibility on the part of the red corpuscles to certain dyes has been 
designated as ansemic or polychromatophilic degeneration (see p. 59). 

Staining with Ehrlich's Haematoxylin-eosin, or Orange -G So- 
lution. — The solution is prepared by dissolving 2.0 grammes of 
hematoxylin in a mixture of 100 grammes each, of distilled water, 
alcohol, and glycerine. To this solution 10.0 grammes of glacial 
acetic acid and an excess of alum are added. After exposure to the 
sunlight for from four to six weeks about 0.5 grm. of eosin or orange-G 
is added. 

The specimens are fixed in absolute alcohol, or by heat (a brief 
exposure only is necessary). They are then left in the stain, in the 
sunlight, for from one half to two hours, when they are thoroughly 
washed in water, dried, and mounted. 

The red corpuscles and eosinophilic granules are colored a bright 
red, the nuclei of normoblasts and megaloblasts a deep black, the 
bodies of the leucocytes a light lilac, and their nuclei a dark lilac. 
The bodies of the lymphocytes, however, are scarcely stained at all, 
while their nuclei appear only a shade lighter than those of the 
nucleated red corpuscles. 

Staining with Chenzinsky's Eosin-methylene Blue Solution. — 
This consists of 40 c.c. of a concentrated aqueous solution of 
methylene blue, 20 c.c. of a 0.5-per-cent. solution of eosin in 70- 
per-cent. alcohol, and 40 c.c. of distilled water. The solution keeps 
fairly well, but should always be filtered before using. A slight de- 
gree of fixation only is necessary. The specimens are stained for 
from six to twenty-four hours in air-tight watch crystals at a tempera- 
ture of from 37° to 40° C. 

The red corpuscles and eosinophilic granules are stained a bright 
red, the nuclei and basophilic granules a deep blue and the malarial 
organisms a light sky-blue. The stain is very useful in studying 
nuclei, and the eosinophilic and basophilic granules. 

Staining with Ehrlich's Tri-glycerin Mixture. — This is com- 
posed of two grammes each, of eosin, aurantia, and nigrosin in 30 
grammes of glycerine. These constituents are brought into solution 
by keeping the mixture in the warm chamber (37° to 40° C.V for 
about one week. 

The specimens must be well fixed, an exposure to a temperature 
of about 110° C. for at least two hours being best. They are then 
allowed to remain upon the stain for from sixteen to twenty-four 
hours, when they are rinsed in water, dried and mounted as usual. 
The red corpuscles are colored orange, the bodies of the leucocytes a 
dirty gray, with dark nuclei, and the eosinophilic granules a bright 
red. 



88 THE BLOOD. 

Staining with Ehrlich's Neutral Mixture. — This consists of five 
volumes of a saturated aqueous solution of acid fuchsin, to which 
one volume of a saturated aqueous solution of methylene blue is 
slowly added, while shaking. The mixture is treated with five vol- 
umes of distilled water and filtered, after having stood for several 
days. The specimens are stained for from five to twenty minutes. 
Only a slight degree of filtration is necessary. 

The red corpuscles are stained the color of fuchsin, their nuclei, 
as well as those of the leucocytes, are black, or a light lilac, the 
eosinophilic granules red and the neutrophilic granules violet. 

Staining with Eosin. — It is most convenient to use an 0.25- to 
0.5-per-cent. alcoholic solution, with which the specimen is stained 
for about one minute. If an 0.1- to 0.5-per-cent. aqueous solution is 
employed an exposure for from 10 to 20 minutes is necessary. The 
degree of fixation need only be slight. 

The red corpuscles are stained a bright red, the protoplasm of the 
leucocytes a faint red, while the eosinophilic granules are deeply 
colored. 

Basic Double Staining. — A saturated aqueous solution of methyl- 
green is treated with a small amount of an alcoholic solution of 
fuchsin. After brief fixation the specimens are stained for five 
minutes. The nuclei appear green, the red corpuscles red, and the 
protoplasm of the lymphocytes the color of fuchsin. The stain is 
especially serviceable for demonstration purposes, in cases of lym- 
phatic leukaemia. 

Staining with Eosin-methylal and Methylene Blue. — The rea- 
gent consists of 10 c.c. of a 1-per-cent. aqueous solution of eosin, to 
which 8 c.c. of methylal and 10 c.c. of a saturated aqueous solution of 
medicinal methylene blue have been added. The mixture is ready 
for use at once, and furnishes very good results. Unfortunately, 
however, it is very unstable and had better be prepared in small 
quantities, when needed. The best results are obtained if the speci- 
mens have been previously carefully heated for about two hours. 
Stainiug for one or two minutes is sufficient. The basophilic gran- 
ules are colored a pure blue, the eosinophilic granules red and the 
neutrophilic granules a reddish-blue. 

Special Staining of Basophilic Leucocytes. — The staining fluid 
consists of 100 c.c. of distilled water, to which 50 c.c. of a saturated 
alcoholic (absolute) solution of dahlia are added. This solution, upon 
clearing, is mixed with 10 to 12.5 c.c. of glacial acetic acid. The 
specimens are stained for from five to ten minutes. 

A saturated aqueous solution of methylene blue may be used for 
the same purpose, and in the same manner. 

With the exception of bacteria only the basophilic leucocytes are 
stained, while the neutrophilic leucocytes are but faintly tinged. 



MICROSCOPIC EXAMINATION OF THE BLOOD. 89 

Neusser's Stain. — In order to stain the basophilic perinuclear 
granules of Neusser the following modification of Ehrlich s tri-acid 
stain should be employed : 

Saturated aqueous solution of acid fuchsin . . . 50 c.c. 

Saturated aqueous solution of orange-G . . . 70 c.c. 

Saturated aqueous solution of methyl-green . . . 80 c.c. 

Distilled water 150 c.c. 

Absolute alcohol 80 c.c. 

Glycerine 20 c.c. 

Ehrlich, however, states in his recent monograph that these forma- 
tions are in reality artefacts, and are rarely observed if the crystalline 
dyes, recommended by him (see above) are used. I have no personal 
experience with these stains. With the Griibler dyes the basophilic 
perinuclear granules are certainly seen in almost every specimen of 
blood, and I am not as yet prepared to admit their artificial origin 
(see p. 69). 

The specimens require only a slight degree of fixation, and are 
stained as with Ehrlich's tri-acid stain. 

Staining with Aronsohn and Philip's Modified Tri-acid Stain. 
— Saturated solutions of orange-G, acid rubin, and methyl-green are 
prepared, and the various ingredients mixed in the following pro- 
portions : 

Orange solution 

Acid rubin solution ...... 

Distilled water 

Alcohol . . . 

To this mixture are added : 

Methyl-green solution ...... 

Distilled water . . . 

Alcohol 



55 c.c. 


50 c.c. 


100 c.c. 


50 c.c. 


65 c.c. 


50 c.c. 


12 c.c. 



The mixture should stand for from one to two weeks before being 
used. A drop of the reagent, added to a Petri-dishful of water, is 
used for staining purposes. The specimen must be carefully fixed by 
heat. An exposure to the stain for twenty-four hours is required. 
It is then rinsed in water and absolute alcohol, cleared in origanum 
oil, and mounted. The various elements are stained as with Ehrlich's 
stain. 

Jenner's Stain. — The reagent is prepared as follows : Equal parts 
of a 1.2-1.25-per-cent. aqueous solution of Griibler's eosin, yellow 
shade, and of a one-per-eent. aqueous solution of methylene blue are 
mixed in an open basin, thoroughly stirred and set aside for 24 hours. 
The resulting precipitate is filtered oil', dried, powdered, washed with 
water, again filtered, and dried. Of the dye which has thus 
been prepared, an 0.5-per-cent. solution in pure methyl alcohol is 



90 THE BLOOD. 

made, to which I further add about 10 per cent, of glycerine. With 
this solution the cover glass specimens are stained for from 1 to 3 
minutes, without previous fixation ; the excess of the stain is rapidly 
poured off, and the specimen rinsed until the film presents a pink 
color. It is then dried in the air and mounted in balsam or oil of 
cedar. 

The red corpuscles are stained a terra-cotta color, the nuclei of the 
leucocytes are blue, the plaques mauve, the neutrophilic granules a 
purplish-red, the eosinophilic granules a bright red and the basophilic 
granules a dark violet. Malarial organisms and bacteria can be 
demonstrated at the same time ; they are colored blue. The basophilic 
granules which are encountered in granular degeneration of the red 
corpuscles are likewise blue, while red corpuscles which are under- 
going polychromatophilic degeneration present a tint, in which the 
terra-cotta color becomes less and less distinct, and the blue color 
more and more predominant (Plate III.). 

It will thus be observed that with Jenner's stain a more complete 
picture is obtained than with Ehrlich's triple stain. In my hands it 
has yielded excellent results, and I can recommend it without reserve. 
In order to obtain perfect pictures, however, cover-glasses must be 
used which are absolutely clean (see p. 84). 

Michaelis' Eosin-methylene-blue Stain. — Two solutions are 
prepared, viz, one containing 20 c.c. of absolute alcohol and 20 c.c. 
of a one-per-cent. aqueous solution of chemically pure methylene 
blue, the other consisting of 28 c.c. of acetone and 12 c.c. of a one- 
per-cent. aqueous solution of chemically pure eosin. The two solu- 
tions are kept in separate bottles and mixed immediately before using, 
in equal proportions. The mixture is placed in a watch crystal and 
covered without delay. The blood films are fixed by heat, or by 
immersion in absolute alcohol for from one to twenty-four hours, 
and then placed in the stain, face downward, for from one-half to 
ten minutes, the time varying with each preparation. The staining 
should be stopped as soon as the blue color, which is first observed, 
has turned to red, as otherwise the nuclei of the leucocytes will be 
decolorized. Should the leucocytes, moreover, be numerous, it is best 
to stop even before this point has been reached. If, on the other 
hand, the blue stain has acted too energetically, the specimen is 
stained a little longer. The preparations are finally rinsed in water, 
thoroughly dried and mounted as usual. The various elements of 
the blood are stained as with Jenner's stain. 

Distribution of the Alkali in the Blood. 

A very good idea of the distribution of the alkali in the blood 
may be formed by making use of the following method, suggested 
by Ehrlich : A drop of blood is carefully spread between two cover- 



MICROSCOPIC EXAMINATION OF THE BLOOD. 91 

glasses, when the air-dried specimens are immediately placed in a 
watch crystal, containing a solution of the free staining acid of ery- 
throsin in chloroform. In a few minutes the specimens have as- 
sumed a bright red color, when they are transferred for a minute or 
two into a crystal containing chloroform. While still moist they 
are then imbedded in Canada balsam. Prepared in this manner, 
the alkaline elements of the blood are colored red. The plasma thus 
presents a distinctly red color, while the red corpuscles have not 
taken up the stain. The protoplasm of the leucocytes and especially 
of the lymphocytes, as also the plaques, the fibrin filaments, and the 
bits of protoplasm derived from the leucocytes are all stained a deep 
red, while the nuclei of the leucocytes remain uncolored. If mala- 
rial organisms are present, these are likewise stained. 

In order to prepare the stain, the following procedure may be em- 
ployed : A saturated aqueous solution of erythrosin (tetraiodo-fluor- 
escin) is acidified with dilute hydrochloric acid, and the staining acid, 
which is thus precipitated, collected on a filter, after having been 
washed with distilled water. The precipitate is dissolved in chloro- 
form, to which it imparts an orange color. This solution is em- 
ployed for staining. In every case care should be had that the 
glass utensils which are used are free from adherent alkali, by wash- 
ing with concentrated acids and then with distilled water. 

The Plaques. 

In addition to the leucocytes and the red corpuscles large num- 
bers of small, roundish elements, measuring about 3 /i in diameter, 
are encountered in the blood, which are free from coloring-matter 
and may be frequently observed collected into small heaps, resemb- 
ling bunches of grapes. These are the blood-plates or plaques of 
Bizzozero. According to Hay em, they represent ordinary red 
corpuscles in an early stage of development, and have hence been 
termed hamiatoblasts. This opinion, however, is not shared by many 
hsematologists, and it is more likely that they are derived from the 
red corpuscles and take some part in the coagulation of the blood. 

According to Osier, their number varies under normal conditions 
between 200,000 and 500,000 per cbmm. Brodie and Russell claim 
that this number is too small, and state that if their improved 
method of counting is used, an average of 635,300 will be found in 
the cbmm. The ratio between the plaques and the red corpuscles 
would thus be 1 : 7.8, accepting 5,000,000 red corpuscles as the aver- 
age normal number for the red. A large increase is observed in 
chlorosis, coincidentlv with an increased coagulability of the blood, 
while in purpura, where this is always much diminished, a corre- 
sponding diminution of the plaques has been noted. Ilayem's state- 



92 THE BLOOD. 

meiit that they occur in greatly diminished numbers in the blood 
of pernicious ansemia lacks confirmation. 

Owing to the rapidity with which the plaques tend to agglutinate 
after the blood has been drawn, it is usually not possible to study 
the individual bodies in fresh specimens, mounted in the ordinary 
way. Various methods have since been devised to overcome this 
difficulty. One of the oldest is to place a drop of Hayem's fluid 
(see p. 93) upon the finger and to puncture the finger through this 
drop. For ordinary purposes this method will suffice, but if it is 
desired to count the plaques the procedure of Brodie and Russell 
should be employed (see p. 98). 

The Dust Particles or Haemokonia of Miiller. — These may be 
seen in any fresh specimen of blood, mounted in the usual manner. 
They are small, generally round, sometimes dumb-bell shaped, color- 
less, highly refractive granules, which manifest very active molecu- 
lar movements. They occur in the plasma of the blood, and are 
apparently not connected with the process of coagulation. Miiller 
found them abnormally numerous in a case of Addison's disease, 
while they were diminished during starvation and in various cachectic 
conditions. Stokes and Wegefarth regard these granules as identical 
with the neutrophilic and eosinophilic granules of the leucocytes. 
They suppose, moreover, that the bactericidal power of the leuco- 
cytes of the blood, and of the serum of man and many animals, is 
due to their presence. 

The Enumeration of the Corpuscles of the Blood by the Method 

of Thoma-Zeiss. 

Of the various instruments employed for the enumeration of the 
blood-corpuscles, that of Thoma-Zeiss is the most satisfactory (Fig. 

It consists of a capillary pipette (#), having a bulb in its upper 
third, the lower end being graduated in parts, numbered from 0.1 
to 1, while above the bulb a mark bearing the number 101 is placed. 
With this goes a counting-chamber (B) measuring exactly 0.1 mm. 
in depth, the floor of which is ruled into sets of 16 small squares, 
each small square underlying a space of ^ -fa-^ cbmm. 

Enumeration of the Red Corpuscles. — In order to count the red 
corpuscles with this instrument the tip of a finger or the lobe of the 
ear is punctured with a sharp-pointed scalpel, after having been 
carefully cleansed with soap and water, alcohol, and finally with 
ether. The exuding blood is drawn into the capillary tube to a 
given mark, generally to 1 or 0.5, according to the degree of dilution 
desired, care being taken that no pressure is exerted upon the finger, 
and that the tip of the instrument comes in contact with the blood 



MICROSCOPIC EXAMINATION OF THE BLOOD. 



93 



only. The point of the tube is then rapidly wiped, and the blood 
diluted with a 3-per-cent. solution of common salt, which is drawn 
into the pipette to the mark 101. 

Toison's fluid is still more convenient as a diluent, as the leuco- 





0.100 mm. 
too mm. j 







I 





Thoma-Zeiss blood-counting apparatus. 



cytes are stained by the methyl- violet, and are thus rendered more 
easily visible. Its composition is the following : 



Distilled water 


. 160 parts. 


Glycerin .... 


. 30 " 


Sodium sulphate . 


8 " 


Sodium chloride . 


1 part. 


Methyl-violet 


0.025 part 



Other solutions such as a 15-20-per-cent. solution of magnesium 
sulphate, a 5-per-cent. solution of sodium sulphate, Hayem's or Pa- 
cini's fluid, may also be employed for the same purpose. 

Formula of Hayem's fluid : 



Bichloride of mercury 
Sodium sulphate 
Sodium chloride 
Distilled water 



0.5 grm. 
5.0 grms. 
2.0 " 

200.0 " 



Formula of Pacini's fluid 

Bichloride of mercury 
Sodium chloride 
Glycerine 
Distilled water 



2.0 grms 
4.0 " 
26.0 " 

22(1.0 " 



The contents of the bulb arc now thoroughly mixed by shaking. 
in which the glass bead CE)> contained in the bulb, aids very ma- 



94 



THE BLOOD. 



terially. The contents of the capillary tube are then cautiously ex- 
pelled, as this only contains the diluting fluid. A drop of the 
mixture is now placed on the counting-chamber, and the cover-slip 
(/•) adjusted, bubbles of air being carefully excluded. When properly 
prepared, Newton's colored rings should be seen at the margin of the 
drop. After allowing the corpuscles to settle — from three to five 
minutes are generally sufficient — they are counted. At least one 
whole field, or if special accuracy is required, two whole fields should 
be gone over — i. e., 200 or 400 small squares, respectively, when 
counting the red, and at least four whole fields when counting the 
white. 

It is convenient to count the red corpuscles in sets of four small 
squares, lying side by side in a horizontal direction, note being 
taken of every corpuscle that touches the upper and left boundary- 
lines of the large squares, no matter whether the body of the cell 









i 


\G. 


18. 










• • o 


•1.J 


.*.*; 


\'\ 


v-,° 


r o*o 


•: 


; 


» J 






. 


.v« 


V' ° 


,' °°. 


•: c 


,\ 


'. 




. • t 






' •*. 


„•"«, 


,°. c <. 


eo » 


•■h J 


«,\ 


",•• 


•; 




;.«. 


•°: 


* 


l\ 


.•1: 




• « ° 


;. 




V." 


• : 




\ : i 


•Jv 


" ' C 


v 


•■ 


■•■ 





o ° 


.*• 1 


. v 


"A ° c 


\V 






.'{ 


° c %° 


• • , 


' ' 


;V, 


{ 


• 


-Yo 


° u ° 


,-, 




o > e * 




o ; o 


,' r w 








, .', 








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•V 


•V 


"'.• 


t_ 


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vv 



Appearance of blood in the Thoma-Zeiss cell. 



lies inside or outside of these lines ; those touching the lower and 
right lines are neglected. It will be noted that every large 
square is separated from its neighbor, both horizontally and verti- 
cally, by a row of small squares traversed by a mesially placed line, 
which serves as a guide to the next large square (Fig. 18). As a 
general rule, it will be found most convenient to ignore these inter- 
mediary squares, account being taken only of the large ones. 

In order to calculate the number of red corpuscles contained in 
one cbmm. of blood the total number noted is divided by the num- 
ber of small squares counted, the result giving the average number 
contained in one small square — i. e., in ^-^q- cbmm. One cbmm. 
of the diluted blood will then contain 4,000 times this number, and 
one cbmm. of undiluted blood the product of this figure and the de- 
gree of dilution. 

Example : Supposing that 1,200 red corpuscles were counted in 
400 small squares, the average number contained in one — i. e., in 



MICROSCOPIC EXAMINATION OF THE BLOOD. 95 

_^^ cbmm. of diluted blood — would be 3, corresponding to 12,000 
corpuscles for each cbmm.; supposing, further, that the blood was di- 
luted 200 times, there would be 2,400,000 in one cbmm. of the un- 
diluted blood. 

Enumeration of the White Corpuscles. — The leucocytes, when 
present in increased numbers, may also be counted with this instru- 
ment, but not less than four whole fields should be covered in the 
examination. 

With an approximately normal number of leucocytes, however, it 
is necessary to resort to special pipettes, which are constructed for a 
dilution of 1 : 10 or 1 : 20. With the diluting fluids mentioned 
above it would be impossible, however, to count the leucocytes in a 
mixture of this proportion, as a large number would be concealed by 
the red corpuscles. An 0.3— 0.5-per-cent. solution of acetic acid is 
therefore used, which destroys the red corpuscles and renders the 
nuclei of the white more distinct. In the absence of a special pipette, 
an ordinary 1-cbmm. pipette, accurately graduated in tenths may be 
employed. 0.9 c.c. of the acetic-acid solution is placed in a watch 
crystal and there mixed with 0.1 c.c. of blood, when the counting 
chamber is filled and covered as described. In order to obtain 
greater accuracy the entire field of the microscope is now counted, a 
lower power being employed with which the rulings are just visible. 
The cubic contents of the field of vision are now determined accord- 
ing to the formula Q = tzy 2 x 0.1. Q, represents the cubic contents 
to be determined ; r, the radius, which is readily ascertained by 
noting the number of vertical lines which cross the field, bearing in 
mind that the distance between two of these is equivalent to ^ mm. 
(the area of each small square being ^1^ mm.), and dividing the 
transverse distance by 2 ; the value, tt, is constant, 3.1416 ; 0.1 rep- 
resents the depth of the chamber. 

If n represents the number of white corpuscles contained in the 
field, the cubic contents of which are Q, the number of corpuscles, 
N, contained in one cbmm. of the diluted blood is ascertained accord- 
ing to the equation : 

Q :n : : 1 : NandN=". 

As the blood has been diluted ten times, the value of X for the 
non-diluted blood will be ^ where n represents the total number of 
leucocytes and f the number of fields counted. 

Example : Supposing the number of leucocytes found in 50 fields 
to have been 600, and the cubic contents of each field 0.03925 
cbmm., the total number of leucocytes contained in one cbmm. ot^ un- 
diluted blood, according to the equation : 

AT 10.n 10X600 , , , , _ 

N= f.Q 50XO03925 ^uld hence be 3,057. 



93 THE BLOOD. 

Special care should be taken to keep the pipette in a clean condi- 
tion. After use it should be rinsed with : (1) the diluting fluid, (2) 
distilled water, (3) absolute alcohol, and (4) ether. If dust or coag- 
ulated blood adheres to the pipette, it should be removed by repeated 
rinsings with strong acids or alkalies, assisted if necessary by a 
bristle. 

Indirect Enumeration of the Leucocytes. 

The number of leucocytes may also be ascertained in an indirect 
manner by accurately counting the number of red corpuscles and leu- 
cocytes in dried and stained specimens with a Zeiss net-micrometer, 
the ratio between the two varieties being thus ascertained. With 
the Thoma-Zeiss apparatus the number of red corpuscles contained 
in one cbmm. of blood is then determined, when the corresponding 
number of leucocytes is found according to the equation : 

IE 



L : K, and L 



r 



where 1 and r represent the number of leucocytes and red corpuscles, 
respectively, as counted in the dried specimens, and where L indi- 
cates the unknown number of leucocytes and R the number of red 
corpuscles in one cbmm. of blood, as determined with the Thoma- 
Zeiss instrument. 

Example : Supposing that 700 red corpuscles and only one leuco- 
cyte were counted in the dried specimen, and that an estimation of 
the red corpuscles with the. Zeiss apparatus indicated the presence of 
5,000,000 in one cbmm. of blood, the corresponding number of leu- 
cocytes would be 7,142, as is apparent from the calculation : 

1R 1.5000000 „.,.. 

L = — = — — = < , 142. 

r /00 

Notwithstanding the apparent simplicity of the process of blood- 
counting, considerable experience is required in order to obtain re- 
sults which are free from unavoidable errors. In using the Thoma- 
Zeiss apparatus errors of more than 2 to 3 per cent, should not occur. 

Differential Enumeration of the Leucocytes. — A differential 
enumeration of the various forms of leucocytes can only be carried 
out in specimens which have been stained so as to bring out the dif- 
ferent granulations. Ehrlichias tri-acid stain has heretofore been em- 
ployed almost exclusively for this purpose. It gives good results if 
the stain has been carefully prepared, but does not color the baso- 
philic granules. During the past few months I have used Jenner's 
stain almost exclusively and have come to the conclusion that in 
many respects it is better than Ehrlich's stain. The granules are 
well shown and the stain can be prepared without any difficulty. 



MICROSCOPIC EXAMINATION OF THE BLOOD. 



97 



In making a differential count of the leucocytes I go over the 
preparation as thoroughly as possible, beginning at the left upper 
corner. A movable stage is of course very convenient, but not a 



Fig. 19. 




Fig. 20. 




Daland's hsematokrit. 



necessity. The individual leucocytes are classified as they are nut 
with, and the percentages finally calculated. To obtain accurate re- 



sults at least 1,000 should be counted 



98 



THE BLOOD. 



Enumeration of the Plaques. 

Method of Brodie and Russell. — The method is an indirect one. 
The red corpuscles are first counted in the usual manner. A drop 
of the staining fluid, composed of equal parts of a 2-per-cent. solu- 
tion of common salt, and a saturated solution of dahlia in glycerine, 



Fig. 21. 




Fig 




Daland's hsematokrit. 



is then placed upon the finger, when this is punctured through the 
drop and the blood is allowed to mix with the reagent. In this 
mixture, the ratio between the plaques and the red corpuscles is 
ascertained, and the total number of plaques, contained in one cubic 



MICROSCOPIC EXAMINATION OF THE BLOOD. 99 

millimeter of blood, determined by calculation. The plaques are 
stained the color of dahlia and can be readily counted. Rapid work, 
however, is essential, as the staining fluid soon attacks the red 
corpuscles. 

Ehrlich suggests the enumeration of the plaques in air-dried speci- 
mens, which have been stained with acid erythrosin. Owing to the 
relatively large amount of alkali which the plaques contain, they are 
stained an intense red with this reagent (see p. 90). 

Rosin finally proposes that the air-dried specimens are fixed for 
twenty minutes by exposure to the vapors of osmic acid, and then 
stained in a concentrated aqueous solution of methylene blue. 

The Haematokrit. 

Within late years the centrifugal machine has also been applied 
to blood-counting, but has not become very popular in the clinical 
laboratory. 

Daland's latest modification of the instrument, originally devised 
by Hedin, is represented in the accompanying illustrations (Figs. 



Fig 




Suction-tube of Daland's hseniatokrit. 



19, 20, 21, 22), and can be recommended to both hospital physicians 
and those engaged in general practice. It consists essentially of a 
metallic frame (Fig. 20), supported upon a spindle which can be 
rotated at high speed, one single revolution of the large handle caus- 
ing 134 revolutions of the frame. Two glass tubes 50 mm. in length 
and having a diameter of 0.5 mm. accompany the instrument. Each 
tube (Fig. 22) bears a scale ranging from to 100, the individual 
divisions of which are rendered easily visible by a lens-front. The 
outer ends of the tube fit into small, cup-like depressions, the bottoms 
of which are covered with thin rubber. The inner extremities are 
held in position by springs. The instrument should be firmly 
secured to a solid table and oiled daily when in use. 

To examine the blood, a rubber tube, provided with a mouth- 
piece (Fig. 23), is slipped over the end of one of the glass tubes, 
when these are filled completely by suction from a drop of blood ob- 
tained from the finger or the ear. The blunt point of the tube is 
then quickly covered with the finger and the tube fixed in the frame. 

LofC. 



100 THE BLOOD. 

This is rotated at a speed of 10,000 revolutions for two or three 
minutes, when the volume of the red corpuscles is directly read off. 
In healthy individuals the volume of the red corpuscles is about 50 
per cent., so that in a given case a proportionate expression of the 
percentage of corpuscles, as compared with the normal, can be ob- 
tained by multiplying the figure upon the scale by two. 

As it has been ascertained that 1 per cent, by volume represents 
about 100,000 red corpuscles, it is only necessary to add five ciphers 
to the percentage- volume found in order to obtain the number of 
red corpuscles in one cbmm. of blood. 

Example : Supposing that in a given case the reading was 35 ; by 
multiplying this figure by 100,000, 3,500,000 would represent the 
number of red corpuscles contained in one cbmm. of blood. 

If normal blood is examined with the hsematokrit, the leucocytes 
will be seen to form a narrow white band at the central end of the 
column of red corpuscles ; a hyperleueocytosis is thus readily recog- 
nized. 



BACTERIOLOGY AND PARASITOLOGY OF THE BLOOD. 

It is generally admitted that micro-organisms do not normally 
occur in the blood ; in conditions which may be said to stand mid- 
way between health and disease, however, they are at times met with. 
In patients suffering from furuncles, for example, bacteria may be 
found in the skin, in the lymphatic glands, and even in the blood of 
neighboring tissues, other symptoms of disease being absent. To 
this condition the term " latent microbism " has been applied by 
Verneuil. 

Under truly pathologic conditions, on the other hand, micro- 
organisms are not infrequently found, and an examination with this 
view will often lead to a correct diagnosis. 

For ease of reference the various organisms that are met with in 
the blood in disease will be described under the headings of the 
respective diseases in which they are found. 

Typhoid Fever. 

In typhoid fever Eberth's bacillus (Plate XL, Fig. 3) may at 
times, though rarely, be demonstrated in the blood, particularly, it is 
claimed, when taken from the roseolar spots. As an aid to diagnosis, 
however, no reliance should be placed upon the results of such an 
examination. 

Widal's Serum Test. 

Very much more important is the fact that the blood serum of 
patients afflicted with typhoid fever possesses the property of caus- 



BACTERIOLOGY AND PARASITOLOGY OF THE BLOOD. 101 

ing arrest of motility and the agglutination of the specific bacilli. 
This observation, originally made by Pfeiffer, was first utilized for 
diagnostic purposes by Widal, in 1896. The method which bears 
his name has now been quite generally adopted in the clinical labo- 
ratory, and must be regarded as a most valuable aid in the diagnosis 
of typhoid fever. The reaction occurs in over 95 per cent, of un- 
doubted cases, and may appear as early as the first day of the dis- 
ease, meaning thereby the first day that the patient spends in bed, 
or the fifth day of general malaise. Such instances, however, are 
very uncommon, and, as a general rule, a positive result is only ob- 
tained after the fifth or the sixth day in bed. In a small number of 
positive cases, on the other hand, the patient may pass through the 
entire course of the disease, and only present typical clumping dur- 
ing convalescence or a subsequent relapse. In every case, therefore, 
in which no reaction is obtained upon first trial, the test should be 
repeated at regular intervals throughout the disease, until a definite 
result is obtained. Intermittence of the reaction, moreover, is very 
common and emphasizes still further the necessity of frequent exam- 
inations in apparently negative cases. 

While in some instances the reaction disappears very soon after 
the temperature reaches normal, and even earlier, it generally con- 
tinues into convalescence and may be observed for months and years 
after the attack. Cases have thus been recorded, where a positive 
reaction could be obtained as long as 37 years after infection. 

The question, whether or not Widal's reaction is a specific reac- 
tion of the typhoid organism, can, I think, be answered in the 
affirmative, notwithstanding the fact that cases of true typhoid fever 
are at times seen, in which no clumping is obtained, and although the 
reaction has been observed in cases which were apparently non- 
typhoid. Such exceptions are no doubt in part due to faulty tech- 
nique, viz, to too low a grade of dilution of the serum, the use of 
old or impure cultures, too long a time-limit of observation, single 
negative tests, etc. On the other hand, there can be no doubt that 
typhoid bacilli are at times present in the body without giving rise 
to symptoms of typhoid fever. In a case of cholelithiasis, reported 
by Cushing, typhoid bacilli were thus found in the gall-bladder, and 
distinct clumping was observed with a dilution of 1—30, although 
no history of typhoid fever could be obtained. There can further 
be no doubt that individuals exist who are naturally immune against 
typhoid fever and that some of the positive results, which have been 
obtained in perfectly healthy individuals who have never had typhoid 
fever, may be explained in this manner. 

While the reaction may hence be regarded as a specific infectious 
reaction of the typhoid bacillus, its value in diagnosis is neverthe- 
less limited. This is largely owing to the fact that in many cases a 



102 THE BLOOD. 

positive result is not obtained before the end of the second or third 
week, and may even be delayed until a relapse occurs. Its per- 
sistence for years after infection is also an obstacle to its general 
utility, not to speak of its occurrence in apparently healthy individuals 
and in diseases in which an association with the typhoid organism is 
not apparent. 

Widal's test is a most valuable aid in the diagnosis of typhoid fever, 
but cannot be relied upon to the exclusion of other symptoms. 

Technique : The method is based upon the fact that typhoid 
serum will cause arrest of motility and agglutination of the specific 
bacilli, even when diluted, whereas clumping of the same organism is 
only obtained with sera from other diseases and healthy individuals, 
when these are used in a more concentrated form. The time-limit 
at which clumping occurs is likewise an important factor, as non- 
typhoid sera are at times met with, in which, notwithstanding a cer- 
tain degree of dilution, agglutination occurs, providing that the spec- 
imen is left for a long time. Both factors, viz, the degree of dilu- 
tion necessary to eliminate the agglutinating power of non-typhoid 
sera, as also the time-limit of observation, have been arbitrarily de- 
termined. Widal originally advised a dilution of 1 : 10 and Griiber 
a time-limit of one-half hour. At the present time there is a ten- 
dency, among German physicians especially, to increase the degree 
of dilution to 1 : 40 and even 1 : 50, and the time-limit to from one to 
two hours. Generally speaking, a positive reaction is of greater 
value the greater the degree of dilution at which it can still be ob- 
tained. A uniform standard, however, is necessary in order to al- 
low a strict comparison of results, and I am personally inclined to 
favor the German standard. 

In any event only a full-virulent, fresh bouillon culture of the ty- 
phoid bacillus, viz, one not older than 16 to 24 hours, should be used. 
The further technique is simple : one volume of blood-serum is di- 
luted with the requisite amount of the bouillon culture, viz, to 10, 20, 
30, 40, or 50 volumes, as the standard may be. Of this mixture 
one drop is mounted on a slide, covered and examined with a mod- 
erately high power. If the case in question is one of typhoid fever 
it will be observed that after a variable length of time the individual 
bacilli, which at first actively dart about the field of vision, become 
quiescent and tend to gather in distinct clumps, while the interspaces 
become entirely free from bacilli or very nearly so. After one-half 
hour, one or two hours, according to the degree of dilution, all mo- 
tion has ceased. When the time-limit has expired and loss of mo- 
tilitv and agglutination have not occurred the result is negative. 
In such an event further examinations should be made on successive 
days. In every case it is well to make a control test with the 
simple bouillon culture, so as to insure the absence of preformed 



BACTERIOLOGY AND PARASITOLOGY OF TILE BLOOD. 103 

clumps and the virulence of the organism; of the latter the degree 
of motility is the best index. 

In order to secure the necessary degree of dilution, various meth- 
ods have been suggested. The simplest and the one generally em- 
ployed in municipal bacteriologic laboratories, is to receive a large 
drop of blood upon a slide or slip of glazed paper, and to allow it to 
dry. A drop of distilled water is then placed on the blood and re- 
mains for several minutes, when it is washed off and intimately 
mixed with the requisite number of drops of the bouillon culture, 
and examined as described. The principal advantages of this method 
are its simplicity, and the fact that the dried blood retains its agglu- 
tinating properties for weeks and months. The results, however, are 
less reliable than with the use of liquid blood. If this is to be em- 
ployed, properly graduated capillary pipettes are prepared, similar to 
the pipettes accompanying the Thoma-Zeiss hsemocytometer. Blood 
is first drawn up to a given mark and expelled into a small watch 
crystal ; the requisite amount of the bouillon culture is then obtained 
with the same pipette and immediately mixed with the blood, when 
a drop of the mixture is examined under the microscope. Steriliza- 
tion of the apparatus used is unnecessary, and each pipette is de- 
stroyed after use. 

If it is desired to keep the liquid blood for any length of time, sim- 
ilar pipettes may be used with a small bulb blown in the middle. 
These are first sterilized by heat and sealed at the ends. Before use, 
one end is broken off, the bulb heated in a spirit flame, and filled by 
capillary attraction. It is then again sealed when the blood may be 
kept indefinitely. Another method which is said to be even more 
reliable than those mentioned, is the following : 

After careful disinfection of the arm, 5 or 6 c.c. of blood are with- 
drawn from one of the superficial veins, by means of a sterilized 
hypodermic syringe, and placed in a sterilized test-tube, measuring 
from 10 to 12 cm. in length. The blood is allowed to stand until 
the serum has separated from the clot, which may be hastened by 
loosening the coagulum from the walls of the tube with a platinum 
needle. Eight drops of the serum are added to 4 c.c. of nutrient 
bouillon, which should be as nearly neutral as possible, when the 
mixture is inoculated with one oese (platinum loopful) of a fresh 
bouillon culture of the typhoid bacillus, not more than 24 hours old. 
The tube is kept at a temperature of 37° C. for 24 hours. At the 
end of this time, and frequently earlier already, the bouillon will be 
absolutely clear, or very nearly so, while little flakes, composed ot' 
the bacilli, will be seen at the bottom and adhering to the sides of 
the tube, if the case under observation is one of typhoid fever : other- 
wise the bouillon has become uniformly cloudy, and a true sediment 
does not occur. A pseudo-reaction may also occur at times, which 



104 THE BLOOD. 

should not be confounded with the one just described. Innumerable 
microscopic, dust-like particles will then be seen, scattered through- 
out the fluid, which can be readily distinguished from the cloudy 
appearance of non-typhoid specimens. It has been suggested that 
this result is obtained in cases of intense infection with the bacillus 
coli communis. Should any doubt arise, it is only necessary to keep 
such tubes for a few hours at a temperature of 37° C, when it 
will be noticed that the dust-like aspect has given place to the ordi- 
nary cloudy appearance, observed in cases which are not typhoid 
fever. 

Of the nature of the substance or substances which cause aggluti- 
nation — agglutinins — very little is known that is definite. It appears 
that in the blood they are intimately associated with fibrinogen and 
globulin, as plasma, from which these two bodies have been removed, 
no longer possesses agglutinating properties. As chemical differ- 
ences, however, apparently do not exist between normal globulin and 
globulin obtained from typhoid blood, it seems likely that the sub- 
stances in question do not form an integral part of the globulin 
molecule, but are perhaps mechanically thrown down, when the 
proteid substances are precipitated. This view is rendered probable 
by the fact that typhoid urine, free from albumin, may likewise cause 
arrest of motility and agglutination of typhoid bacilli. Attempts to 
separate the agglutinins from the proteids of the blood have thus far 
not been successful. 

The milk of immunized animals, or of typhoid patients, acts like 
the blood and in it the agglutinins are apparently associated with 
casein. Exposure of such milk to a temperature of 80° C. abolishes 
its agglutinating power. Very interesting is the observation of 
Malvoz, that very dilute solutions of safranin and vesuvin act upon 
the typhoid bacilli, as typhoid serum does, and upon these bacilli 
only. 

Pneumonia. 

Recent research has brought to light the interesting fact that 
in fatal cases of acute croupous pneumonia the specific diplococcus is 
quite frequently present in the blood, while in cases ending in re- 
covery it is only exceptionally encountered. I have found, as a mat- 
ter of fact, that a positive result is obtained in more than 89 percent, 
of the fatal cases. The invasion of the blood usually occurs twenty- 
four to forty-eight hours before death, but may also take place at an 
earlier date or be delayed. From the standpoint of prognosis a 
bacteriologic examination of the blood may thus be of considerable 
importance. It should be remembered, however, that while a posi- 
tive result is always a symptom mali ominis, there are cases on record 
in which recovery occurred notwithstanding the presence of diplococci 



BACTERIOLOGY AND PARASITOLOGY OF THE BLOOD. 105 

in the blood. In such cases metastatic infection has probably oc- 
curred. 

The examination, which should be repeated every day, is con- 
ducted as follows : After disinfection of the arm one of the super- 
ficial veins is compressed with a finger and punctured with an ordi- 
nary hypodermic syringe, which has been previously sterilized in 
boiling water. Five c.c. of blood are aspirated and agar-tubes — 
liquefied at 40° C. — inoculated, each with 1 c.c. of the blood. Plates 
are then prepared and kept at a temperature of from 35° to 37° C. 
The colonies number from 2 to 200, and appear as small, round, 
grayish, jelly-like drops, which are quite characteristic. During 
their growth they cause a greenish discoloration of the blood-agar. 
Other bacteria possess the same property, but in a less marked degree 
than the diplococcus pneumoniae. 

The individual organism (Plate XIII.. Fig. 2) is capsulated and 
usually occurs in pairs, arranged end-to-end or in short chains. At 
times, however, the chains are quite long, and it may then be difficult 
to distinguish it from streptococci. It is easily stained with the 
common anilin dyes. In order to differentiate the capsule the follow- 
ing method, suggested by Welch, is best employed : Spread and 
dried cover-glass preparations are treated first with glacial acetic acid, 
which is allowed to drain off, and is replaced (without washing in 
water) with anilin gentian-violet solution. The staining-solution is 
repeatedly added until all the acid is displaced. The specimen is 
now washed in a weak salt-solution (about 2 per cent.), and examined 
in this, and not in balsam. The capsule and coccus can thus be 
differentiated. 

The organism also grows on gelatin without causing its liquefac- 
tion. 

Sepsis. 

The importance of a careful bacteriologic examination of the blood 
in cases of septic infection has now been definitely established. 
Large quantities of blood are, however, necessary, and reliance 
should never be placed upon a microscopic examination of a single 
drop. In doubtful cases it is best to cup the patient and to inocu- 
late agar-plates and bouillon-tubes with the serum. The animal ex- 
periment, viz, the injection of 0.5 to 2.0 c.c. into the peritoneal 
cavity of white mice will also be found most valuable. Petruschky 
has shown that in severe cases of septic infection it is almost always 
possible to find streptococci in the blood, while in the milder cases a 
negative result is reached. lie has found, moreover, that while as :i 
general rule the presence of streptococci will justify a grave prog- 
nosis quoad vita/m, death does not necessarily occur in every case. 
His results are tabulated below : 



106 



THE BLOOD. 



Negative Results. 



5 cases 

2 



of puerperal fever ..... 

phlegmonous abscess, associated with erysipelas 
simple erysipelas 
erysipelas (convalescing) . 
endocarditis .... 
pleurisy with effusion 

" with pericarditis . 
pneumonia .... 

acute articular rheumatism 
scarlatina ..... 
typhoid fever .... 
phthisis (in 3 of which a general pyogenic infection 
was found post-mortem ; 2 streptococci ) 



Deaths 

. 1 

. 

. 

. 

. 

. 

. 

. 1 

. 

. 

. 



Positive Eesults. 

5 cases of sepsis, following phlegmonous abscesses, 
or pulmonic infection (4 streptococci, 
1 staphylococci) .... 

9 " u puerperal infection (8 streptococci, 1 
staphylococci) ..... 

1 case of ulcerative endocarditis (streptococci) . 

2 cases of mixed infection ( streptococci ) . 



Deaths. 



Recoveries. 



Streptococci are frequently met with in the blood after death from 
diphtheria, while the staphylococcus aureus and Loeffler's bacillus are 
more rarely seen. In scarlatinal sepsis streptococci have likewise 
been found. 

Of other micro-organisms which may be met with in septic con- 
ditions the diplococcus pneumoniae is the most common. It has 
been found in peritonitis, associated with carcinoma of the uterus, in 
cases of suppurative oophoritis, following childbirth, in cases of biliary 
abscess at the time of the chill, etc. Friedlander's bacillus has also 
been found. In several cases of gonorrheal septicaemia the gono- 
coccus has been isolated during life. Proteus vulgaris has been 
found in a few instances. The bacillus aerogenes capsulatus which 
is so frequently seen after death has also been obtained from the blood 
of living patients. 

The Staphylococcus pyogenes aureus occurs in the form of minute 
spherical bodies, averaging about 0.8 p. in diameter, which readily 
stain with the basic anilin dyes, as also with Gram's method. They 
usually occur in clumps, but may also be seen in pairs and in short 
chains. The organism grows on all culture-media, and in the pres- 
ence of oxygen gives rise to the formation of an orange-yellow pig- 
ment. Gelatin is rapidly liquefied ; it coagulates milk and clouds 
bouillon. The Staphylococcus pyogenes albus and citreus differ from 
the aureus by the absence of pigment in the first and by the forma- 
tion of a lemon-yellow pigment in the second. 

The Streptococcus pyogenes (Plate VI., Fig. 1) occurs in chains of 
spherical cocci which usually vary from four to twenty in number. 



PLATE VI. 



FIG. 1. 



FIG. 3. 



Streptococcus Pyogenes. (Abbott.) 
FIG. 2. 




•\ 



Bacillus Anthraeis, highly mag- 
nified to show Swellings and Con- 
cavities at extremities of the Single 
Cells. (Abbott.) 



O 



Qq 



Ol 



c%^ 0° // ® 

-^; ^^ oo 

HoR# ° 

o u 

Spirilla of Relapsing Fever. 

(v. Jaksch.) 



FIG. 4. 










« 



- 











Malaria] Blood Stained with Chenzinsky-Plehn's Solution. 
(Personal Observation.) 



BACTERIOLOGY AND PARASITOLOGY OF THE BLOOD. 107 

The size of the individual organism is somewhat greater than that of 
the staphylococcus, but may vary even in one and the same chain. 
It is readily stained with the basic anilin dyes and also with Gram's 
method. It grows on all culture-media at the temperature of the 
room, forming small gray granular colonies on agar and gelatin. As 
a rule, it does not liquefy gelatin, and it may or may not coagulate 
milk and cloud bouillon. Several varieties are recognized, viz, 
Streptococcus brevis, which forms short chains ; Streptococcus longus, 
which occurs in long chains ; streptococci which render bouillon 
cloudy, and those which do not ; streptococci which form flocculent, 
sandy, scaly, or viscous sediments. 

The Streptococcus conglomeratus grows without clouding the bouil- 
lon, in the form of dense, separate particles, scales, or thin mem- 
branes at the bottom and sides of the tube, and on shaking the sedi- 
ment it breaks up into little specks, without producing uniform, diffuse 
cloudiness. The chains are long and interwoven in conglomerate 
masses. (Welch.) 

Anthrax. 

The bacillus of anthrax, as first pointed out by Pollender, Brouell, 
and Davaine, is frequently met with in the blood, where it should 
be sought for in doubtful cases, by staining with Loemer's method. 
To this end cover-glass preparations are floated for five to ten min- 
utes on a mixture of thirty c.c. of a concentrated alcoholic solution 
of methylene blue and 100 c.c. of a 1 : 10,000 solution of potas- 
sium hydrate ; they are then washed for five to ten seconds in an 
0.5-per-cent. solution of acetic acid, treated with alcohol, dried, 
and mounted in balsam. Thus stained, the bacilli appear as rods 
measuring from 5 fi to 12 p. in length by 1 p in breadth, and usually 
present a segmented appearance, the extremities being slightly thick- 
ened. Spores are not found, as the organism multiplies by fission. 
When present in large numbers it is not even necessary to stain, as 
the organisms can then be seen without difficulty in fresh speci- 
mens (Plate VI., Fig. 2). 

In doubtful cases, in which a microscopic examination of the blood 
yields negative results, a few c.c. of the blood may be injected into 
a mouse or a guinea-pig, in the blood of which the bacilli will soon 
be found in enormous numbers, if the disease is anthrax. 

Acute Miliary Tuberculosis. 

In acute miliary tuberculosis tubercle-bacilli have repeatedly been 
observed in the blood, but while their presence may be regarded as 
pathognomonic of the disease 4 , the search for them is mosl tedious 
and often in vain. Nevertheless a careful examination of the blood 



108 THE BLOOD. 

is indicated in doubtful cases, but the fact should ever be borne in 
mind that only a positive result is of value. 

For methods of staining and description of the tubercle-bacillus 
the reader is referred to the chapter on Sputum. 

Glanders. 

In glanders the specific bacillus is constantly present in the blood, 
and may be demonstrated by staining the dried preparations on a 
cover-glass for five minutes with a concentrated alcoholic solution 
of methylene blue, mixed just before using with its own volume of 
a 1 : 10,000 solution of potassium hydrate. From this mixture the 
specimen is passed for a second or two into a 1-per-cent. solution of 
acetic acid which has been tinged a faint yellow by the addition 
of a little tropseolin 00 solution ; it is then decolorized by washing 
in water containing two drops of concentrated sulphuric acid and 
one drop of a 5-per-cent. solution of oxalic acid for every 10 c.c. 

Fig. 24. 

-^ ? -** / " 

Bacillus of glanders. (Abbott.) 

In specimens thus stained the bacilli appear as short rods, measur- 
ing from 2 fj. to 3 fx in length by 0.3 fx to 0.4 ti in breadth, often 
containing a spore at one end (Fig. 24). 

Influenza. 

In the sputum of influenza a specific organism has been described 
by Pfeiffer and Kitasato ; it is also said to be constantly present in 
the blood of such patients. The organism in question appears in 
the form of minute rods measuring 0.1 fx in breadth by 0.5 /x in 
length, occurring either singly or in chains of threes or fours. In 
suitably prepared specimens, owing to the fact that their poles take 
up the stain more readily than the middle portion, they convey the 
impression of diplococci. 

Canon advises the following method for demonstrating their pres- 
ence in the blood : Cover-glass preparations that have been allowed 
to dry at an ordinary temperature are placed in absolute alcohol for 
five minutes and are then stained at a temperature of 37° C. for from 



BACTERIOLOGY AND PARASITOLOGY OF THE BLOOD. 109 

three to six hours, with Chenzinsky-Plehn's solution (see p. 87). 
The specimens are washed in water, dried between layers of filter- 
paper, and mounted in balsam. Stained in this manner the red cor- 
puscles are colored red, and the leucocytes, as well as the bacilli, 
blue. As a rule, only from four to twenty are found in one prepara- 
tion, usually occurring singly, but also in groups. Owing to the 
fact that they are found in the blood only during the acme of the 
disease, Canon recommends the examination of the sputum for diag- 
nostic purposes, a view with which my own observations are entirely 
in accord. 

Relapsing Fever. 

Relapsing fever is characterized by the presence in the blood, and 
here only, of spirilla or spirochete which bear the name of their 
discoverer, Obermeier. In order to search for these organisms no 
special precautions are necessary. After having carefully cleansed 
the finger, as described, a drop of blood is mounted on a very thin 
cover-glass. This is directly inverted upon the slide, when the 
specimen is ready for examination ; an oil-immersion lens is not re- 
quired. Attention is drawn to the presence of these organisms by 
certain disturbances which are noticeable among the red corpuscles, 
and upon careful examination it will be seen that these are caused by 
the wriggling movements of the spirilla. The spirochetal Obermeieri 
are long, slender filaments, measuring from 36 // to 40 // in length 
by 0.3 fi to 0.5 ju in breadth, and present from eight to twelve in- 
curvations of equal size with tapering extremities (Plate VI., Fig. 
3). These last two characteristics serve to distinguish this species 
from that described by Ehrenberg, in which the radius of the in- 
curvations is not the same in all, and in which the extremities do not 
taper. 

The number of spirilla which may be found in a drop of blood 
varies, being greater during the access of the fever, when twenty, or 
even more, may be observed in the field of the microscope. They 
occur either singly or in bunches of from four to twenty, specimens 
such as those figured in the table being frequently seen. In the 
quiescent stage they are sometimes arranged in the form of rings or 
of the figure 8. After the crisis they seem to disappear entirely, and 
their presence during an afebrile period may therefore be regarded 
as indicating a pseudocrisis. During the afebrile periods small, bright, 
round bodies have been described as occurring in the blood, which 
according to some are spores, but according to others merely represent 
debris of the spirilla. 

Culture-experiments have not been very satisfactory, although 
Koch, at a temperature of from 10° to 1 1° C. observed an increase 
in their number. 



110 THE BLOOD. 

That confusion should ever arise in distinguishing the spirilla of 
relapsing fever from the free nagella observed at times in malarial 
blood seems to me very improbable. 

Yellow Fever. 

In yellow fever Sanarelli's bacillus icteroides may be isolated from 
the blood duriug life. Wasdin and GiddiDgs found it in twelve 
cases out of fourteen, after the third day of the disease, and also ob- 
tained it from the remaining two after death. In other diseases it 
was not found. For details see the report of the commission of med- 
ical officers of the marine hospital service, detailed by the U. S. 
government to investigate the cause of yellow fever. 

Malaria. 

The discovery in the blood of a specific micro-organism belonging 
to the class of protozoa, the plasmodium malariw of Laveran, and of 
its invariable presence in the different forms of this disease, must be 
regarded as one of the most important in clinical medicine. This is 
not the place to point out how frequently a diagnosis of malarial 
fever based upon clinical symptoms alone has proved false, or how 
often a tubercular, a syphilitic or a septic infection has been over- 
looked and termed malaria. It will suffice to say that errors of this 
kind, in view of our present knowledge and the ease with which they 
can be avoided by every physician, should no longer occur. The 
diagnosis of malaria should in every case be based upon a microscopic 
examination of the blood. 

The search for the specific organism, it is true, may be very tedi- 
ous at times, but it will always be crowned with success if the dis- 
ease in question is malaria. Again and again I have seen cases in 
which the clinical symptoms alone would not have warranted the 
diagnosis of malaria, and in which the true nature of the disease was 
cleared up only by a careful examination of the blood ; and cases 
have often been seen in which the diagnosis of malaria based upon 
clinical symptoms alone was disproved by the absence of plasmodia 
from the blood and the post-mortem examination. 

The parasite in question, as I have already stated, is a protozoon 
and belongs to the class of hsematozoa, representatives of which are 
found in the blood of various animals, such as the rat, frog, tortoise, 
carp, various birds, etc. Three varieties are known to occur in the 
blood of man, viz, the parasite of tertian, quartan, and sestivo-au- 
tumnal fever. The life history of these organisms is now quite well 
understood, and it is known that in addition to the intra-corporeal 
cycle of development, which takes place in the human body, there is 
yet another, an extra-corporeal cycle, which occurs in certain mos- 



BACTERIOLOGY AND PARASITOLOGY OF THE BLOOD. Ill 

quitoes, belonging to the genus Anopheles. Infection occurs through 
the bites of such mosquitoes, which themselves have been infected 
by sucking the blood of malarial patients. This has now been 
abundantly demonstrated by Ross, Grossi, and others and can be re- 
garded as an established fact. 

Method of Examination. — The necessary amount of blood is 
best obtained by puncture of a finger or the lobe of the ear, 
after this has been thoroughly cleansed with soap and water and 
dried. The first few drops are wiped away. A small drop 
of blood is then received upon a cover-glass held with a pair of 
forceps, care being taken that the tip of the drop only is touched, 
when the specimen is immediately transferred to a slide. Cover- 
glasses and slides must be absolutely clean, and it is best to keep 
both in bottles filled with alcohol or a mixture of alcohol and 
ether. If these precautions are taken and the drop is not too large, 
the corpuscles will spread out in an even layer between the two 
glasses and retain their principal features. Pressure should always 
be avoided. For the examination of the specimens an oil-immersion 
lens is almost indispensable, unless the observer has been thoroughly 
trained in hematologic research. 

Whenever the specimens can be examined within two to six hours 
after their preparation, it is best to use fresh blood. In that case a 
drop is mounted as usual, but guarded against evaporation by sur- 
rounding the cover-glass with a little melted paraffin. If this is im- 
possible dried blood-films must be employed. These are then stained 
according to one of the following methods : 

Futcher's Method. — The air-dried films are fixed for one minute 
in an 0.25-per-cent. solution of formalin in 95-per-cent. alcohol. 
But, as it is important that this solution should be made up fresh 
for each examination, it is more convenient to keep a 10-per-cent. 
aqueous solution of formalin on hand, and to add four or five drops 
of this to 10 c.c. of 95-per-cent. alcohol, just before using. The 
specimens are then rinsed in water, dried between filter paper, and 
stained for from ten to fifteen seconds with a carbolated solution of 
thionin. This is prepared by adding 20 c.c. of a saturated solution 
of thionin in 50-per-cent. alcohol, to 100 c.c. of a 2-per-cent. solu- 
tion of carbolic acid. The thionin carbolate which is thus formed 
constitutes the active staining principle. After washing off the ex- 
cess of stain the preparations are dried with filter paper and mounted 
as usual. Thus prepared the malarial parasites appear as reddish- 
violet bodies and are readily seen. The method is of special value 
in staining the ring-shaped bodies of the sestivo-autumnal infection, 
which are difficult to see in unstained specimens, and usually do not 
stain well with eosin and methylene blue. 

Jenner's Method. — This method has already been described (p. 
89), and like Futcher's method furnishes o- ( hh1 results. 



112 THE BLOOD. 

Plehn's Method. — The solution employed has the following com- 
position : 

Concentrated aqueous solution of methylene blue . . 60 c.c. 

0.5 % solution of eosin in 75 % alcohol . . . 20 c.c. 

Distilled water . . . . . . . . 40 c.c. 

Aqueous solution of sodium hydrate (20 %). . . 12 drops. 

The specimens are fixed in absolute alcohol for from 3 to 5 minutes. 
After drying they are stained for from 5 to 6 minutes, rinsed in water, 
dried between filter paper and mounted. The red corpuscles are 
stained red, and the nuclei of the leucocytes and the malarial organ- 
isms blue. 

Staining with Iodine. — The air-dried blood films are exposed to- 
the vapors of iodine until they have assumed a pronounced yellow 
color. To this end a few grammes of metallic iodine are placed in 
a small glass dish, provided with a well-fitting top. The specimens 
are left in this dish, arranged on little glass tripods or similar con- 
trivances, blood side down, for ten minutes or longer. They are 
then mounted in a drop of syrup of laevulose and examined as usual. 
Special fixation is generally not necessary, but at times specimens are 
met with in which a dissolution of the haemoglobin takes place in 
the syrup. In such an event a brief fixation is required, for which 
purpose Futcher's formalin or absolute alcohol may be employed. 

With this method the red blood-corpuscles practically present a 
natural color, more or less intensified, and the malarial organisms 
appear as in fresh blood. I have found this procedure especially 
serviceable in demonstrating the natural appearance of the parasite 
to students at a time when fresh blood was not available. 

The followiDg forms may be found in the blood : 

1. Hyaline Non-pigmented Intracellular Bodies. — These 
apparently represent the earliest stage in the development of the 
parasite, and are found in all forms of malarial fever, being especially 
abundant during the latter part of the paroxysm or immediately 
thereafter. At first sight they may be mistaken for vacuoles, but 
upon closer examination it will be found that they exhibit distinct 
movements of an amoeboid character, and may thus be easily recog- 
nized with a little experience. 

The rapidity with which these changes in the form of the organism 
occur in the tertian type of ague is most astonishing, and sketches 
of any one phase can often, indeed, be made only from memory ; in 
quartan fever the movements are much slower and far less extensive. 

In the irregular fever of the aestivo-autumnal form amoeboid 
movements may likewise be observed, but more commonly the para- 
site assumes a ring-like appearance, and does not throw out distinct 
pseudopodia. If these forms are carefully observed, however, it will 



PLATE VII. 














L Schmidt fec/t 



The Parasite of Tertian Fever. 



i, Normal Red Corpuscle; 2-4, Non-pigmented Stage of the Organism, showing Amceboid Movements; 
5-7, Progressive Pigmentation and Growth; 8-11, the Process of Segmentation; 12, Young Forms; 13, Large 
Extra-cellular Organism; 14, Mode of Formation of Extra-cellular Body; 15, Small Fragmented Extra-cel- 
lular Organism; 16, Flagellate Body and Free Flagella. Unstained Specimen. (Personal Observation.) 



PLATE VI 



FIG. 1. 















L Schmidt fecit 

The Parasite of Aestivo-Autumnal Fever, 
i. Normal Red Corpuscle; 2-10, Gradual Growth of the Organism; 11 and 12, Segmenting Bodies; 
13, Young Forms ; 14-22, Crescents, Ovoids and Spherical Bodies, with and without Bih ; 23, Flagellate 
Cody. Unstained Specimen. (Personal Observation.) 



FIG. 2. 




(h 






L Schmidt fecit 



The Parasite of Quartan Fever. 
l, Normal Red Corpuscle; 2-6, Gradual Growth of the Organism; 7, Pigmented Extra-cellular Body 



8, Segmenting Body; 9, Young Forms; i< 
stained Specimen. (Personal Observation. 1 ) 



Vacuolated Extra-cellular Body; n, Flagellate Form. Un- 



BACTERIOLOGY AND PARASITOLOGY OF THE BLOOD. ±16 

be found that they are not absolutely quiescent, but alternately ex- 
pand and contract. 

In tertian fever the organism (Plate VII.) is pale and indistinct, 
while in quartan fever it is sharply outlined and somewhat refractive 
(Plate VIII., Fig. 2). In the sestivo-autumnal form the organism is 
usually much smaller than in the tertian type, and the ring-like 
bodies frequently present a distinctly shaded aspect at some point in 
their interior which closely resembles the darker portion in the 
centre of a normal corpuscle (Plate VIII., Fig. 1). It is thus possible, 
even at this stage in the development of the parasite, to distinguish 
between fever of the tertian, quartan, and sestivo-autumnal type. 

The numbers in which these small, non-pigmented intracellular 
organisms may at times be met with is most astonishing. In a case 
of pernicious malarial fever of the algid type, which I had occasion 
to examine, and in which a history of only one week's illness with- 
out chills was obtained, normal red corpuscles were indeed only 
exceptionally found. The case was one of the sestivo-autumnal form 
of fever. 

2. Pigmented Intracellular Organisms. — These represent 
a later stage in the development of the parasite, and, like the non- 
pigmented intracellular bodies, are met with in all types of malarial 
fever. Their appearance, however, differs considerably in the various 
forms. In tertian fever minute granules of a reddish-brown color 
appear in the bodies of the organism very soon after the paroxysm. 
These gradually increase in number, while the invaded corpuscles 
proportionately become paler and paler, until finally only an indis- 
tinct shell-like outline can be discerned. In fresh specimens the 
granules, which often assume the form of little rods, resembling 
bacteria, exhibit most active molecular movements, attracting atten- 
tion at once. The body of the parasite, which during its develop- 
ment has gradually increased in size, is probably hyaline, and may 
still be seen to undergo amoeboid movements. These are not nearly 
so active, however, as in the non-pigmented stage. The movements, 
moreover, cannot be followed so readily, owing to the presence of 
the granules. At first sight these appear to be scattered in small 
collections throughout the red corpuscle, and the impression may be 
gained that several organisms are present at the same time. Upon 
closer investigation, however, it will be seen that this is only appar- 
ently the case, and that the grannies are confined to the bulbous 
extremities of the pseudopodia of a single parasite. Before the end 
of forty-eight hours the organism has filled out the entire red cor- 
puscle, which at the same time has attained a larger size than nor- 
mal. The amoeboid movements become less and less marked, and 
the pigment-granules, which may still be quite active, tend to colled 
about, the periphery (Plate VII.). 
s 



114 THE BLOOD. 

In quartan fever pigmented intracellular bodies likewise appear 
very soon after the paroxysm. The individual granules, however, 
are somewhat larger, of more irregular size, and darker in color than 
those seen in the tertian type (Plate VIII., Fig. 2). Instead of ex- 
hibiting active molecular movements, moreover, they are almost en- 
tirely quiescent, and are usually grouped along the periphery of the 
organism. While amoeboid movements can at first be observed, 
these become less and less marked, until finally, at the end of from 
sixty-four to seventy-two hours, they have ceased. The organism 
then presents a round or ovoid form, but does not fill the red cor- 
puscle entirely. It is curious to note that in this form of ague the 
red corpuscles do not become decolorized, but rather darker than 
normally, and at times specimens may be seen which present a 
distinctly greenish or brassy appearance. When the parasite has 
become fully developed the corpuscle is smaller than normally, and 
on staining it may be seen that the organism is still surrounded by 
a narrow zone of corpuscular protoplasm, even when this is not ap- 
parent in unstained preparations. 

The pigmented intracellular bodies which may be found in sestivo- 
autumnal fever (Plate VIIL, Fig. 1) can be readily distinguished from 
those observed in tertian and quartan ague. As in these forms pig- 
ment-granules also appear after the paroxysm, they are never 
numerous, however, and often only one or two minute, dark gran- 
ules can be detected near the periphery. The organism even in the 
later stages of its development, scarcely ever occupies much more 
than one-third of the corpuscle. Usually the granules exhibit 
scarcely any movements. As in the quartan type of ague, decolor- 
ization of the red corpuscles does not occur, and here, as there, a 
greenish brassy appearance is often observed. At times the red cor- 
puscles are shrunken, crenated, or spiculated. 

At the beginning and during the paroxysm forms are at times seen 
in which the few pigment-granules that may be present have gathered 
in the centre of the parasite and formed a solid clump. From the 
fact that these are only observed during the paroxysm, and that 
central blocks of pigment are only found during the stage of seg- 
mentation (see below) in tertian and quartan ague, Thayer and others 
conclude that these bodies are pre-segmenting forms of the parasite. 
This belief is further strengthened by the observation that pigment- 
bearing leucocytes are then also seen, which in the other types of 
fever are likewise only found at this time. The evolution of the 
non-pigmented intracellular body in sestivo-autumnal fever is now 
fairly well understood and it is known that the principal changes 
occur in the spleen. 

3. Segmenting Bodies. — In cases of tertian and quartan fever the 
progress of segmentation may be directly observed under the micro- 



BACTERIOLOGY AND PARASITOLOGY OF THE BLOOD. 115 

scope, if specimens of blood are obtained just prior to or during the 
chill. In tertian fever organisms will then be seen in which the de- 
struction of the red corpuscles has advanced to a stage where it is 
only possible to make out a pale contour of the original host. The 
parasite itself has gradually assumed a granular appearance, and the 
pigment-granules, which until then have exhibited pronounced mo- 
lecular movements, now become quiescent, larger and rounder, and 
show a distinct tendency to collect in the centre of the body. Here 
they form a roundish mass in which the individual components can 
scarcely be made out. While this change in the position of the pig- 
ment is taking place, beginning segmentation of the surrounding 
granular protoplasm will be observed. This at first is most marked 
at the periphery, from which delicate striae will gradually be seen to 
extend toward the central mass, dividing up the protoplasm into a 
number of oval bodies which closely resemble the petals of a flower 
(Plate VII.). Still later these bodies, which in reality are the spor- 
ules of the parasite, will be found scattered in an irregular manner 
throughout the interior of the organism. The apparent envelope 
then disappears, and the sporules, which in tertian fever usually 
number from fifteen to twenty, lie free in the blood. Quite fre- 
quently, also, a sudden expulsion of the little bodies is observed and 
the impression gained as though the envelope had been burst asunder. 
Upon closer inspection, even at the petal stage, it will be seen that 
almost every sporule presents a tiny dot in its interior, which may 
at first sight be mistaken for a pigment granule, but which in all 
probability is a nucleus. After the expulsion of the sporules these 
are frequently seen to move about in an active manner, but sooner 
or later they come to rest. 

While the progress of segmentation is very frequently observed to 
proceed in the manner described, this is not invariably the case. It 
may thus happen that segmentation occurs before the pigment- 
granules have had time to gather at the centre, or that the parasitic 
protoplasm breaks up into sporules directly without the intervention 
of the petal stage. In every case, however, the formation of sporules 
is directly associated with the occurrence of a paroxysm, and repre- 
sents the asexual type of reproduction of the parasite. 

The ultimate fate of the sporules is not definitely known, but it is 
likely that they in turn invade new corpuscles, cause their destruc- 
tion, and become segmented, thus giving rise to a new generation. 
As the process of segmentation, moreover, coincides in time with the 
occurrence of the chill, it is apparent that the interval elapsing between 
two consecutive chills — /'. c, the type of the ague — depends upon the 
rapidity with which the non-pigmented forms arrive at maturity. 

En quartan ague the manner in which segmentation takes place 
differs somewhat from that observed in the tertian form. It will 



116 THE BLOOD. 

here be observed that the pigment granules, which have gathered 
along the periphery of the organism, as the parasite approaches ma- 
turity, become arranged in a stellate manner, and apparently reach 
the centre through certain definite protoplasmic channels. Here 
they finally form a dense clump, and while the protoplasm assumes 
a finely granular appearance segmentation proper begins and pro- 
ceeds as in the tertian form. In quartan ague, however, the num- 
ber of segments is smaller, varying between six and twelve. The 
entire segmenting body, moreover, is smaller than in the tertian 
form, and the segments are arranged in a more symmetrical manner. 
Here, indeed, the most perfect rosettes are observed (Plate VIII., 
Fig. 2). _ 

In asstivo-auturnnal fever segmenting bodies are only exception- 
ally seen in the peripheral blood, and it appears that the process of 
reproduction occurs principally in the spleen. The pre-segmenting 
forms described here undergo segmentation in a manner closely re- 
sembling that observed in tertian fever. The number of segments, 
moreover, is about the same, varying, as a rule, between ten and 
twenty. The segmenting body itself, however, is much smaller than 
in either the tertian or quartan form, and it is not possible to dis- 
tinguish any remains of the original host. 

4. Ceescextic, Ovoid, and Spherical Bodies (Plate VIII. , 
Fig. 1). — These are only observed in cases of sestivo-autumnal fever, 
when this has persisted for at least one week. At first sight they 
apparently bear no relation to the other forms which have already 
been described, and it has long been an open question whether or 
not these bodies actually represent a stage in the life-history of the 
common malarial parasites. Grassi and Feletti have applied the 
name Laverania malarice to this form. More recent investigations 
have rendered it probable that they are directly derived from the 
pigmented intracellular forms. Specimens may thus be met with in 
which crescentic bodies are found in the interior of red corpuscles 
that have lost but little of their original color. Such observations, 
however, are not common. The typical crescents which are usually 
seen are highly refractive bodies, somewhat larger than a red cor- 
puscle, measuring from 7 a to 9 fi in length by 2 fi in breadth. 
Their extremities are usually rounded oif and joined by a delicate, 
curved line bridging over their concave border. This is supposed 
to represent the remains of the original host. At other times this 
hood-like appendage is found along the convex border. The little 
pigment-granules and rods, which are always found in the interior 
of the crescents, are generally collected about the centre of the 
body, but they are occasionally also seen in one of the horns. While 
usually quiescent, a migration of some of the granules toward one 
extremity and back to the central mass may at times be observed. 



BACTERIOLOGY AND PARASITOLOGY OF THE BLOOD. Ill 

The ovoid and spherical bodies, which are usually much smaller than 
the crescants, exhibit the same general features, however, and are 
often likewise provided with a little hood. It is now known that 
the spherical bodies develop from the ovoids, and these again from 
the crescents. Like the crescents, the ovoid and spherical forms 
may be found in the interior of red corpuscles. 

5. Extracellular Pigmented Bodies. — In tertian and quar- 
tan ague some of the pigmented intracellular bodies, instead of un- 
dergoing segmentation, when they have arrived at maturity, may 
be seen to leave their hosts and to appear as such in the blood. At 
the same time they increase considerably in size, and in the tertian 
form may indeed become as large as a polynuclear leucocyte (Plate 
VIL). The pigment-granules, moreover, exhibit an activity in their 
movements, which is most astonishing, and never observed under 
other conditions. The outline of the parasite is then usually irregu- 
lar and quite indistinct. Upon careful observation it will be seen 
that in some of these bodies the movements of the granules after 
a while become less and less marked, and finally cease, while the 
body of the parasite itself becomes still more irregular in outline. 
This appearance is undoubtedly referable to the death of the organ- 
ism. In others a gradual fragmentation is observed, small particles 
of the pigmented mother-substance being cut off from the parent- 
form. It is thus quite common to see the original parasite break 
up into four or five smaller bodies, in which the movements of the 
pigment-granules persist for some time. Sooner or later, however, 
even these cease, the outlines of the bodies become more and more in- 
distinct, and death occurs. In still others the formation of vacuoles 
may be observed, the pigment-granules at the same time becom- 
ing quiescent. This process is likewise regarded as one of degenera- 
tion. Most interesting, however, is the fact that flagellation may 
occur in some of these extracellular forms. It will then be observed 
that the pigment-granules which exhibit a most surprising activity 
tend to collect near the centre of the organism, while at the same 
time curious undulating movements may be made out along its con- 
tours. Suddenly one or more (one to six) extremely slender fila- 
ments will be seen to protrude from as many points on the pe- 
riphery, presenting minute enlargements here and there in their 
course (Plate VII. ). The length of these filaments, or flagella, as 
they are termed, varies considerably. As a rule it docs not exceed 
the diameter of from five to eight red corpuscles, but much longer 
specimens are at times observed, and it appears to me that in most 
illustrations they arc represented too short. AVith these flagella the 
organism exerts most active whipping movements, scattering the red 
corpuscles to the right and left. Attention is, indeed, usually first 
drawn to the presence of these bodies by the disturbance which they 



118 THE BLOOD. 

cause in the field of vision. Occasionally one of the flagella may be 
seen to become detached from the body of the parasite and to move 
about among the corpuscles in a rapid, snake-like manner. In mi- 
croscopic specimens they gradually come to a rest and often curl 
into a spiral. 

That difficulty should ever arise in distinguishing such detached 
flagella from the spirilla of relapsing fever seems very improbable, as 
the true nature of these formations is shown by the presence or ab- 
sence of other forms of the malarial organism. 

Beyond the fact that the flagellate organisms in tertian fever are 
larger than in the quartan form, no special points of difference exist 
(Plate VIII. , Fig. 2). In sestivo-autumnal fever similar changes may 
be observed. In crescents it is thus not at all uncommon to observe 
a small hyaline protrusion from the surface of the organism, which 
may later become detached. This process was formerly regarded as 
one of regeneration, but it is questionable whether this is actually the 
case. In other specimens, again, true fragmentation, or vacuoliza- 
tion, may occur, and flagellate bodies are met with in this type of 
fever as well as in tertian and quartan ague. The flagellates, as in 
quartan fever, are smaller than those observed in the tertian form, 
but other points of difference do not exist (Plate VIII., Fig. 1). 

The true significance of these flagellate organisms has until recently 
not been understood, but we now know that they represent the male 
element in the sexual reproduction of the malarial parasite, and the 
beginning of a new cycle of development, which takes place outside 
of the human body, in the bodies of certain mosquitoes. The begin- 
ning of this cycle was first observed by MacCallum in the blood of 
infected crows. He here discovered, that when one of the flagella 
broke loose, it almost always sought out another full grown form of 
the parasite, which had not undergone segmentation and penetrated 
this, just as the spermatozoon penetrates the ovum. Subsequently 
he observed the same process in the blood of the human being. The 
further development of the fertilized forms, however, does not take 
place in the human blood, but m the bodies of mosquitoes. The fer- 
tilized organism then penetrates the stomach wall of the insect and 
here gives rise to the formation of little cysts, in which after about 
seven days numerous irregular, rounded ray-like striae appear. After 
a time the capsule of the cysts bursts, and the delicate thread-like 
bodies are set free in the body cavity of the mosquito, and shortly 
after appear in the salivary glands. These bodies apparently repre- 
sent the young parasites, which result from the sexual reproduction 
of the adult organism. If at this stage of their development the 
infected mosquito is allowed to bite the human being, malarial infec- 
tion results, with the appearance in the blood of the hyaline forms 
lready described. 



BACTERIOLOGY AND PARASITOLOGY OF THE BLOOD. 119 

From the above description it will be seen that three forms of 
the malarial parasites may be found in the blood, viz, the parasite of 
tertian, quartan, and sestivo-autumnal fever, and it has been shown 
that these three forms may be readily distinguished from each other. 
It should be mentioned, however, that in tertian and quartan fever 
several groups of the same organism may be present at one time, 
and as the process of segmentation coincides with the occurrence of 
a paroxysm, it will be readily seen that the number of paroxysms 
within a given time depends directly upon the number of groups 
which may be present in the blood. If a double infection with the 
tertian parasite has occurred, one group of organism may thus have 
just reached the segmenting stage, while the second group has only 
attained a twenty-four hours' growth, the result being that maturity 
is reached by the two groups on successive days. Quotidian fever 
is then the result. Should still more groups be present, the clinical 
picture will accordingly become more complicated. In quartan 
ague, similarly, double quartan fever will occur if two groups are 
present, and triple quartan fever if three groups are present at one 
time. Mixed infections, further, are also possible. 

In conclusion, it may not be out of place to refer to the presence 
of pigment-bearing leucocytes in the blood of malarial patients. 
These are quite constantly met with during the paroxysm, and it is 
indeed often possible to observe the process of phagocytosis directly 
under the microscope (see Fig. 13). The forms which are taken up 
are the central pigment-clumps of organisms that have undergone 
sporulation, the small, fragmented extracellular forms, the flagellate 
bodies, and even the segmenting bodies. In every case where pig- 
ment-bearing leucocytes — which are probably always of the neu- 
trophilic, polynuclear variety — are observed malarial fever should 
be suspected and a careful examination made, as a melanaemia has 
so far only been observed in this disease, in relapsing fever, and in 
connection with the rare melanotic tumors, in which not only leuco- 
cytes containing melanin occur in large numbers, but also masses of 
this pigment float free in the blood. 

FILARIASIS. 

Filaria sanguinis hominis (Lewis), *//»., filaria Wuchereri (da 
Silva Lima) ; filaria Bahcrofti (Cobbold) ; filaria Mansoni ; trichina 
cystica (Salisbury) ; trichina sanguinis hominis nocturna (Manson). 

Several varieties of the parasite (Fig. 25), which belongs to the 
class of nematodes, have been observed in the blood of man. Among 
these are the filaria sanguinis hominis nocturna, filaria sanguinis 
hominis diurna, or filaria sanguinis hominis, var. major, and filaria 
var. minor. 



120 



THE BLOOD. 



The female of filaria nocturna, according to Manson's description, 
is " a long, slender, hair-like animal, quite three inches in length, 
but only one one-hundredth inch in breadth, of an opaline appear- 
ance, looking as it lies in the tissues like a delicate thread of catgut, 
animated and wriggling. A narrow alimentary canal runs from 
the simple club-like head to within a short distance of the tail, the 
remainder of the body being almost entirely occupied by the repro- 
ductive organs. The vagina appears about one twenty-fifth of an 
inch from the head ; it is very short and bifurcates into two uterine 



Fig. 21 




Filaria sanguinis homiuis. ( After Lewis.) 



horns, which, stuffed with embryos in all stages of development, run 
backward nearly to the tail." (Osier.) The male worm is rarely 
seen, and is much smaller than the female. TThile the adult parasite 
has its habitat in the lymphatic channels, the embryos, which are set 
free in enormous numbers, invade the blood-current, in which they 
mav be readilv found at night ; during the day an examination of 
the blood will usually yield negative results. This periodicity may, 
however, be reversed by having the patient sleep in the daytime and 
be about at night. Each embryo has an envelope of its own, which 
is hyaline in appearance and within which the young worm, measur- 
ing 0.34 mm. in length by 0.0075 mm. in breadth, is able to extend 
and contract itself. In fresh preparations these organisms are readily 
detected by the disturbance which their movements create among the 
corpuscles, when they are apparently transparent and homogeneous ; 
but after some time, when the worm has come to rest, it will be seen 
that they are granular and transversely striated. 

As the mere presence of these parasites usually does not produce 
symptoms, and as an examination of the blood made in daytime, as 
already stated, generally yields negative results, attention is only 
drawn to their presence when symptoms poiutiug to an occlusion 
somewhere in the course of the lymphatic channels exist, as evi- 
denced by chyluria (which see), elephantiasis, or lymph scrotum. 



BACTERIOLOGY AND PARASITOLOGY OF THE BLOOD. 121 



DISTOMIASIS. 

Bilharzia hsematobia (Cobbold), syn., gynaecophorus (Diesing) ; 
distomum haematobium (Bilharz) ; schistosoma (Weinland) ; distoma 
capense (Harley) ; thecosoma (Maguin-Tandon). 

The Bilharzia hsematobia belongs to the class of trematode pla- 
todes, and has never been met with in the United States or in 
Europe. According to Bilharz, the greater portion of the Fellah 
and Coptic population of Egypt is infected. It may give rise to 

Fig. 26. 




Bilharzia hsematobia. Male and female, with eggs. (v. Jaksch.) 

diarrhoea, hematuria, and ulceration of the mucous surfaces. The 
male is smaller, but thicker than the female, measuring from 12 to 
14 mm. in length ; on its abdominal surface a deep groove is found 
with overlapping edges, which serves for the reception of the female 
(Fig. 26). 

While the adult parasite is but rarely seen in the blood, its ova 
are frequently found. These are slender bodies, measuring 0.12 
mm. in length by 0.04 mm. in breadth, and are provided with a 
distinct spike-like little projection, which issues from one extremity 
or the side. 



CHAPTER II. 



THE SECRETIONS OF THE MOUTH. 



SALIVA. 

Normal saliva is a mixture of secretions derived from the sub- 
maxillary, sublingual, parotid, and mucous glands of the mouth. 
It is a colorless, inodorous, tasteless, somewhat stringy and frothy 
liquid, and serves the purpose of aiding in the acts of mastication, 
deglutition, and digestion. The quantity secreted in twenty-four 
hours amounts to about 1,500 grammes. 

General Characteristics. 

Normal saliva has a specific gravity of from 1.002 to 1.009, cor- 
responding to the presence of from 4 to 10 grammes of solids. Its 
reaction is usually slightly alkaline ; it may, however, become acid 
at times, when lactic acid fermentation takes place in the mouth. 
This acid, according to Magittot, corrodes the enamel of the teeth, 
and may ultimately produce dental caries. 

Chemistry of the Saliva. 

In order to give an idea of the general composition of the saliva 
the following analyses are appended, the figures corresponding to 
1,000 parts by w r eight : 



Water .... 


995.2 


991.20 


988.1 


Ptyalin 1 .... 


1.34 


1.30 


1.3 


Mucin \ 
Epithelium J " 


1.62 


2.20 


2.6 


Fatty matter . 






0.5 


Sulphocyanides 


6.06 


0.04 


0.09 


Alkaline chlorides . 


0.81 






Disodium phosphate 


0.91 


2.20 


"*3.4 


Magnesium and calcium salts 


0.01 






Alkaline carbonates - 









In order to demonstrate the presence of the sulphocyanides it is 
usually only necessary to heat a few c.c. of the pure saliva, faintly 
acidified with hydrochloric acid, with a dilute solution of perchlo- 

1 These figures are too high, 
alcohol. 



they refer to the total precipitate obtained with 



122 



SALIVA. 123 

ride of iron, when a red color will be seen to develop. If necessary, 
larger quantities, such as 100 c.c., are evaporated ; the test is then ap- 
plied to the concentrated fluid. Of organic matter a little albumin, 
mixed with mucin, and about 1 gramme of urea pro litre are found. 
Of all these substances, the ptyalin is especially interesting from a 
physiologic point of view. It may be prepared in a pure state, ac- 
cording to Gautier's method : 

To a large quantity of saliva alcohol (98-per-cent.) is added as long 
as a flocculent precipitate is seen to form. This is collected upon a 
small filter and dissolved in a little distilled water. The solution 
thus obtained is treated with several drops of a solution of bichloride 
of mercury, in order to remove albuminous material, which is filtered 
off. The excess of mercury is removed by means of sulphuretted 
hydrogen, when the remaining liquid is evaporated at a temperature 
of from 35° to 40° C, and taken up with strong alcohol. The in- 
soluble residue is dissolved in a little water, filtered, dialyzed in 
order to remove inorganic salts, and finally precipitated with strong 
alcohol, when ptyalin will separate out in light flakes. Obtained 
in this manner ptyalin is a white, amorphous substance, soluble in 
water, dilute alcohol, and glycerine. In neutral or even slightly al- 
kaline solutions, but not in acid solutions, it rapidly transforms 
boiled starch into dextrin and sugar at a temperature of from 35° 
to 40° C. This transformation takes place according to the equation : 

Starch. Maltose. Achroodextrin. Ervthrodextrin. 

10C 6 H 10 O 5 + 4H 2 = 4C 12 H 22 O n + C 6 H 10 O 5 + C 6 H 10 O 5 

In order to test for the presence of ptyalin a few c.c. of saliva are 
filtered and added to a solution of starch ; the mixture is placed in 
the warm chamber for some time, when it is tested with sulphate 
of copper or iodine. At first, starch gives a blue color with iodine ; 
after the reaction has proceeded further a red or violet-red color is 
obtained, indicating the presence of erythrodextrin, while no change 
in color at all results when achroodextrin only is present. The 
maltose may be recognized by the fact that it turns the plane of 
polarization more strongly to the right than glucose ; it also reduces 
Fehling's solution, and may thus be recognized in the absence of 
glucose. 

The test for nitrites, which may likewise be present in the saliva, 
is conducted in the following manner : About 10 c.c. of saliva are 
treated with a few drops of Tlasvay's reagent and heated to a temper- 
ature of 80° C, when in the presence of nitrites a rod color will de- 
velop. The reagent is prepared as follows : 0.5 gramme oi^ sul- 
phanilic acid in L 50 c.c. of dilute acetic acid is treated with 0.1 
gramme of naphtylamin, dissolved in 20 c.c. of boiling water. After 
standing for some time the supernatant fluid is poured off and the 



124 



THE SECRETIONS OF THE MOUTH. 



blue sediment dissolved in 150 c.c. of dilute acetic acid. . The solu- 
tion is kept in a sealed bottle. 

Microscopic Examination of the Saliva. 

If normal saliva is allowed to stand, two layers will be seen to 
form, viz, an upper clear and a lower cloudy layer, which latter con- 
tains certain morphologic elements. Among these salivary cor- 
puscles, pavement epithelial cells and micro-organisms are found, 

(Fig. 27). 

Fig. 27. 




%o%S°» % •" 



Buccal secretion (eye-piece III.,obj. Reichart, 1/15, homogeneous immersion ; Abbe's mirror, 
open condensers). Friedlander's and Giinther's method (v. Jaksch). a, epithelial cells ; b, sali- 
vary corpuscles ; c, fat-drops ; c\, leucocytes ; e, spirochaeta buccalis ; /, comma-bacillus of mouth ; 
g, leptothrix buccalis ; h, i, k, various fungi. 



The salivary corpuscles resemble white corpuscles very closely, 
but differ in their greater size and coarser appearance. The epi- 
thelial cells are large, irregular, polygonal cells, provided with well- 
defined nuclei and nucleoli ; they exhibit certain irregularities in 
size, according to their origin, and belong to the class of pavement 
or stratified epithelium. 

Micro -organisms. — While schizomycetes and moulds are only 
exceptionally found in the mouth under normal conditions, and are 
then undoubtedly derived from ingested food, bacteria are always 
present in large numbers, and it cannot be surprising that all forms 
which are found in the air, food, and drink may here be encountered 
(Plate IX., Fig. 1). Some of these, such as the leptothrix buccalis 
innominata, bacillus buccalis maximus, leptothrix buccalis maxima, 
iodococcus vaginatus, spirillum sputigenum, and spirochete dentium, 
are always present. Together with other bacteria they have been 
found in carious teeth, in abscesses communicating with the mouth 
and pharynx, and in exudates on the mucous membranes of these 
parts. In all probability, however, they are non-pathogenic. In 
this connection it is interesting to note that in contradistinction to 



PLATE IX. 



FIG. 1 



-V 




mm 



Bacteria of the Mouth. (Cornil Babes. 



FIG. 2. 




Leptothrix Bueealis. (v. Jakseh I 



SALIVA. 125 

the bacteria Avhich are only temporarily found in the mouth the ma- 
jority of those which are constantly present cannot be cultivated on 
artificial media. 

Important from a practical standpoint is the fact that a number 
of pathogenic micro-organisms may at times be found under normal 
conditions. The diplococcus pneumoniae, also known as the pneu- 
mococcus of Fraenkel and Weichselbaum, the diplococcus lanceolatus, 
the micrococcus lanceolatus, the micrococcus septicaemiae sputi, and 
the micrococcus pneumoniae cruposae (Sternberg), has thus been found 
in a virulent condition in from 15 to 20 per cent, of healthy indi- 
viduals, and it is even claimed that in a non- virulent state it is 
constantly present in the mouth. Streptococci are likewise frequently 
observed, but usually possess but little virulence or none at all, 
when obtained from the healthy mouth and tested upon animals. 
Pyogenic staphylococci may also be found at times, but are less 
common than the streptococci. Most important is the occasional 
occurrence of the diphtheria bacillus in the mouths of individuals 
who have not been exposed to contagion. Welch l mentions that 
virulent organisms were found by Park and Beebe in the healthy 
throats of eight out of 330 persons in New York, who gave no his- 
tory of direct contact with cases of diphtheria. Two of these eight 
persons later developed the disease. Non-virulent bacilli Avere found 
in twenty-four individuals of the same series, and the pseudo-diph- 
theria bacillus in twenty-seven. Other pathogenic bacteria which 
may be found in normal mouths are the micrococcus tetragenus, the 
bacillus pneumoniae of Friedlancler, the bacillus crassus sputigenus, 
and the bacillus coli communis. 

It is interesting to note that the secretions of the mouth and 
throat, as most secretions of the body, possess a certain degree of 
germicidal power. The staphylococcus aureus, the streptococcus 
pyogenes, the micrococcus tetragenus, the typhoid bacillus, and the 
cholera spirillum, when present in moderate numbers, are thus 
killed by the saliva. The diphtheria bacillus, however, is more 
resistent, and may survive for twenty-four to forty days. It has 
been found as a matter of fact that the organism may be demon- 
strated in the throats of some individuals who have passed through 
an attack of diphtheria, during several weeks after all the clinical 
symptoms have disappeared. The diplococcus pneumoniae is even 
said to grow well in saliva, although it rapidly loses its virulence. 
By then cultivating it upon pneumonic sputum, however, the viru- 
lence of the organism is again restored. The individual bacteria 
will be considered in detail later on. 

1 Dennis' System of Surgery : Surgical Bacteriology. 



126 THE SECRETIONS OF THE MOUTH. 

Pathologic Alterations. 

It has been mentioned that about 1,500 grammes of saliva are 
secreted in the twenty-four hours. This quantity is, however, sub- 
ject to great variation. An increase is thus frequently noted in 
pregnancy, in various neurotic conditions, in inflammatory diseases 
of the mouth, in dental caries, following the administration of pilo- 
carpin, in poisoning with mercury, acids, and alkalies. The quan- 
tity is diminished in all febrile diseases, in diabetes, and often in 
nephritis. The effect of psychic influences upon the secretion of 
saliva as well as of other glands is well known, an increase or decrease 
in the flow being produced under various conditions. 

In determining whether or not salivation actually exists the physi- 
cian should not only be guided by the statements of his patients, but 
an actual estimation of the amount, secreted within a definite period of 
time, should be made. Hysterical individuals not infrequently com- 
plain of " salivation/ 7 when a direct estimation will show that the 
amount is not only not increased, but actually diminished. 

Among qualitative changes may be mentioned an increase in the 
amount of urea, which has been repeatedly observed, especially in 
nephritis. 

Urea may be demonstrated as follows : The saliva is extracted 
with alcohol, the filtrate evaporated, and the residue dissolved in 
amyl alcohol. This is allowed to evaporate spontaneously, when 
crystals of urea will separate out, and may then be examined micro- 
scopically and chemically. (See Urine.) 

Bile-pigment and sugar have thus far never been found in the saliva. 

Of drugs, potassium iodide and potassium bromide rapidly pass 
into the saliva. Upon this property the indirect examination of the 
gastric juice for its digestive power — i. e., the presence or absence 
of free hydrochloric acid — by means of the potassium iodide and 
fibrin packages of Gtinzburg, is partly based. 

In order to test for potassium iodide strips of filter-paper moist- 
ened w T ith starch solution are immersed in the saliva which has been 
acidified with nitric acid ; in the presence of potassium iodide the 
starch-paper turns blue. 

The Saliva in Special Diseases of the Mouth. 

Catarrhal Stomatitis. — In this affection the quantity of saliva is 
increased. Microscopically an increased number of epithelial cells 
and many leucocytes are noted, their number depending upon the 
intensity of the morbid process. 

Ulcerative Stomatitis. — In this condition, following mercurial 
poisoning or scurvy, the same appearance is noted microscopically as 
in simple stomatitis. In addition there may be necrotic tissue, red 



SALIVA. 



127 



blood-corpuscles, and innumerable leucocytes. The reaction of the 
saliva is intensely alkaline, the color markedly brown, and its odor 
fetid. 

Gonorrhoeal Stomatitis. — The number of cases of gonorrhoeal 
stomatitis that have thus far been recorded is small. The disease, 
however, has as yet received but little attention, and is probably 
more common than is generally supposed. In the adult it may be 
contracted through coitus contra naturam, while in the newborn the 
infection is undoubtedly brought about in the same manner as the 
corresponding disease of the conjunctiva. In suspected cases the 
exudate which forms upon the gums, the tongue, and the palate 
should be examined for the presence of gonococci. In adults the 
organism has thus far not always been found ; in the newborn, how- 
ever, Rosinski has succeeded in demonstrating its presence in all 
cases examined. 

Thrush. — Oidium albicans (Fig. 28) is most commonly seen in 
children, but may also occur in adults, and especially in phthisical 
individuals, sometimes lining the whole mouth. If in such cases a 
bit of the membrane is pulled off and examined microscopically, it 
will be found to consist of epithelial cells, leucocytes, and granular 
detritus, with a network of branching, band-like formations, which 



Fig. 




Oidium albicans, the vegetable parasite of muguet or thrush. (Reduced from Cn. Robin. ) 

present distinct segments. The contents of the segments are clear, 
and usually contain two highly refractive granules — the spores, one 
of which is situated at each pole. These segments diminish in size 
toward the end of each band, their contents at the same time becom- 
ing slightly granular. 



TARTAR. 

In a bit of tartar scraped from the teeth actively moving • spiro- 
chsetse are seen, as well as long, usually segmented bacilli, frequently 



128 THE SECRETIONS OF THE MOUTH 

forming bands which are colored a bluish-red by a solution of iodo- 
potassic iodide. Leptothrix buccalis, shorter bacilli, which are not 
colored by the above reagent, micrococci, and a large number of 
leucocytes and epithelial cells which have undergone fatty degenera- 
tion are also found. 



COATING OF THE TONGUE. 

A brown coating of the tongue is often observed in severe infec- 
tious diseases, and consists of remnants of food and incrnstated blood. 
Microscopically, in addition to a large number of epithelial cells, 
enormous numbers of micro-organisms and a large number of dark, 
cell-like structures, probably derived from desquamated epithelial 
cells, are found. The white coating of the tongue contains epithelial 
cells in large numbers, many micro-organisms, and a few salivary 
corpuscles. 



TUBERCULOSIS OF THE MOUTH. 

In cases of lupus and the so-called benign form of tuberculosis 
of the mouth it is rarely possible to demonstrate the presence of 
tubercle bacilli, even in scrapings taken from the base of the ulcers, 
or in the diseased tissue itself, while in cases of ulcerative disease 
associated with phthisis in its advanced stages they may be fre- 
quently found in large numbers. In some cases, however, their 
demonstration is by no means easy. In the saliva they are only 
exceptionally seen. 



ACTINOMYCOSIS. 

In cases of actinomycosis it is occasionally possible to demon- 
strate the presence of the specific organism in or about carious teeth. 
More commonly, however, the patients are not seen until the primary 
symptoms of the disease have disappeared, when the typical kernels 
can no longer be found at the original points of entry or have 
become unrecognizable owing to calcification and retrogressive 
changes. 

Usually the disease has already progressed to the formation of a 
distinct tumor or abscess, and it may be then necessary to make an 
exploratory incision and to examine the scrapings which are brought 
away. The number of kernels which may be found is at times very 
small, but a careful examination will probably always lead to their 
detection, if the disease in question is actinomycosis. 



COATING OF THE TONSILS. 129 

COATING OF THE TONSILS. 

Pharyngomycosis Leptothrica. 

In the props from the crypts of the tonsils in cases of fol- 
licular tonsillitis, as also in persons who have had frequent attacks 
of tonsillitis, according to Chiari, epithelial cells and long, segmented 
fungi — the leptothrix buccalis (Plate IX., Fig. 2) — which are col- 
ored bluish-red with a solution of iodo-potassic iodide, are seen. At 
times patches composed of these fungi extend over a considerable 
area of the tonsils, so that it may be doubtful whether or not the 
disease is a beginning diphtheria. A microscopic examination will 
in such cases settle all doubts. 

Tonsillitis. 

In tonsillitis a large number of bacteria have been isolated from 
the pseudo-membranous deposits. Among the more important 
which are supposed to bear a causative relation to the disease, may 
be mentioned the various streptococci, staphylococci, less commonly 
the pneumococcus, the diplococcus of Brison, the bacillus coli com- 
munis, the bacillus of Friedlander, and in a few isolated instances the 
micrococcus tetragenus. 

Diphtheria. 

Recognizing the great importance of an early diagnosis in such a 
dreaded disease as diphtheria, an examination for Loffler's bacillus 
has become just as important to-day as that for the bacillus of tuber- 
culosis, and every physician should make himself familiar with the 
methods employed for its recognition. 

By means of a sterilized, stout platinum loop, a pair of forceps, or 
a cotton swab, a piece of membrane is scraped from the tonsils, the 
soft palate, or the pharynx and at once transferred to a sterilized 
test-tube, closed with a pledget of cotton. A particle of the mem- 
brane is then spread in as thin and uniform a layer as possible, upon 
a cover-glass, by means of the platinum loop or forceps, which have 
been previously passed through the flame of a Bunsen burner. When 
dry the specimen is fixed by being passed through the flame ot' -a 
Bunsen burner three or four times, when it is ready for staining. 
For this purpose Loffler's alkaline solution of methylene blue, which 
consists of 30 c.c. of a concentrated alcoholic solution of methylene 
blue in 100 c.c. of an aqueous solution of potassium hydrate [\ : 10,- 
000), may be advantageously employed, the specimen being stained 
for from five to ten minutes. It is then rinsed in water, placed on 
a slide, the excess of water removed with filter-paper, and examined 
with a one-twelfth oil-immersion Lens, 



130 THE SECRETIONS OF THE MOUTH. 

A dahlia-rnethyl-green solution may likewise be employed. This 
consists of 10 grammes of a 1 -per-cent. aqueous solution of dahlia- 
violet and 30 grammes of a 1 -per-cent. aqueous solution of methyl- 
green. The specimen is stained for from one to two minutes. 

If it is desired to employ Gram's method, the specimen is most 
conveniently stained for three minutes with a freshly prepared con- 
centrated alcoholic solution of gentian-anilin water. This is pre- 
pared by adding anilin oil to 10 c.c. of distilled water, drop by 
drop, thoroughly shaking after the addition of each drop, until the 
solution becomes opaque. It is then filtered and treated with 10 c.c. 
of absolute alcohol and 11 c.c. of a concentrated alcoholic solution 
of gentian-violet. The specimen is decolorized in a solution com- 
posed of 1 gramme of iodine and 2 grammes of potassium iodide, 
dissolved in 300 c.c. of water. After remaining in this solution for 
five minutes the specimen is rinsed in alcohol and the process re- 
peated until the violet color disappears. It is then transferred to 
absolute alcohol, oil of cloves, and mounted in balsam. 

Cultures should also be made, preferably upon a mixture of blood- 
serum and bouillon, as recommended by Loffler. This is composed 
of three parts of blood-serum and one part of bouillon, containing 
10 per cent, of peptone, 3 per cent, of grape-sugar, and 0.5 per cent, 
of sodium chloride, the mixture being solidified in the usual manner. 
Upon this medium Loffier's bacillus grows so much more rapidly 
than other organisms which are usually present in the secretions of 
the mouth and throat, that at the end of twenty-four hours they 
often form the only colonies that attract attention. Should other 
colonies of similar size be present these are generally quite different 
in appearance. In this manner a diagnosis can be made upon the 
day following the inoculation of the tube. 

In the absence of blood-serum bouillon, alkaline bouillon, nutrient 
gelatin, nutrient agar, glycerin-agar, and potato may be employed. 
Coagulated egg-albumin, as pointed out by Booker, and milk are 
also good soils. 

The colonies are large, round, elevated, and grayish-white in 
color, with a centre that is more opaque than the slightly irregular 
periphery. The surface of the colony is at first moist, but after a 
day or two assumes a dry appearance. 

The bacillus (Fig. 29) is non-motile and varies in size and shape, 
its average length being from 2.5 //to 3 jul, its breadth from 0.5 jjl 
to 0.8 a. Its morphologic characteristics are so peculiar as to render 
its identification upon cover-slip preparations and in sections of the 
diphtheritic membrane an easy matter, in most cases. 

Sometimes the organism appears as a straight or slightly curved 
rod ; but especially characteristic are irregular and often bizarre 
forms, such as rods with one or both ends terminating in a little 



COATING OF THE TONSILS. 131 

knob, and rods broken at intervals, in which short, well-defined 
round, oval, or straight segments can be made out. 

Some forms stain uniformly, others in an irregular manner ; the 
most common present the appearance of deeply stained granules in 
faintly stained bacilli. 

Fig. 29. 



f? 






,mtk, 


$ 




,/.— 


w^ 


«a*» 


gg 


f 


f">ar 




Bacillus of diphtheria. (Abbott.) 
«. Its morphology when cultivated on glycerin agar-agar. b. Its morphology as seen in cultures 

on Loftier' s blood-serum. 

Streptococci are also seen, as a rule, and it may be said that the 
gravity of a case is directly proportionate to the number of strepto- 
cocci present. 

It is important to note that diphtheria bacilli may still be found 
in the throat for weeks after all clinical symptoms have disappeared. 
Patients should hence be isolated until a bacteriologic examination 
has demonstrated the absence of the organism. 



CHAPTER III. 
THE GASTRIC JUICE AND GASTRIC CONTENTS. 

THE SECRETION OF GASTRIC JUICE. 

The gastric juice is the result of the glandular activity of the 
stomach, and the only secretion of the digestive tract which presents 
an acid reaction. 

As is well known, the mucous membrane of the stomach is covered 
throughout its entire extent by a single layer of cylindrical epithe- 
lium, which dips down in places to line the orifices and larger ducts 
of the numerous tubular glands with which it is beset. Of these 
two kinds have been described, viz, the fundus and pyloric glands, 
so named from the location in which they are principally found. In 
the secretory portion of a fundus gland two different sets of cells 
can be distinguished, one being small, granular, and polyhedral or 
columnar, bordering upon the narrow lumen of the tube, termed 
chief or principal cells by Heidenhain ; they are also known as cen- 
tral or adelomorphous cells. These stain with anilin dyes to only 
a slight extent. The others, known as parietal, adelomorphous, or 
oxyntic cells are variously situated between the adelomorphous 
cells and the membrana propria, being most numerous in the 
necks of the glands. They are larger than the chief cells, oval 
or angular and finally granular in structure ; they possess a strong 
affinity for the anilin dyes. The pyloric glands, which are found 
only in the region of the pylorus, on the other hand, are character- 
ized by the greater length of their ducts, which are also lined by 
the cylindrical epithelium of the mucous membrane proper. The 
secretory portion of these glands is represented by a single layer of 
short and finely granular, columnar cells, which closely resemble the 
chief cells of the fundus glands. In addition to these a few isolated 
cells, the cells of Nussbaum, are found, which in structure and in 
their behavior to anilin dyes resemble the parietal cells. 

Upon chemical examination the gastric juice is found to consist 
essentially of water, free hydrochloric acid, pepsin, rennet (a milk- 
curdling ferment), mucus, and certain mineral salts. 

Of these constituents the hydrochloric acid is secreted by the parie- 
tal cells, pepsin and the milk-curdling ferment by the chief cells of 

132 



TEST-MEALS. 133 

the fundus and the pyloric glands, while the mucus is the product of 
the cylindrical goblet-cells lining the stomach and the wider portions 
of its glandular ducts. 

It must be borne in mind, however, that the ferments mentioned 
do not exist in the cells as such, but as zymogens, which are trans- 
formed into the ferments through the activity of the free hydro- 
chloric acid. According to modern investigations, moreover, the zy- 
mogens only are secreted by the cells. 

Until recently it was supposed that the gastric juice is only secreted 
upon appropriate stimulation of the nervous mechanism of the stom- 
ach, either directly or indirectly and that the stomach in its quiescent 
state — i. e.j when not digesting — is empty. The researches of 
Schreiber and Martius, however, have rendered the correctness of 
this view very doubtful, as they were able to obtain quantities of gas- 
tric juice, varying from 1 to 60 c.c, from the non-digesting stom- 
ach of every normal person examined ; and I have likewise never 
failed to obtain a few c.c. under the same conditions. 

TEST-MEALS. 

Although the secretion of gastric juice takes place continuously, 
the amount that can usually be obtained from the non-digesting 
organ is not sufficient for analytical purposes. It is, therefore, nec- 
essary to stimulate the glandular apparatus of the stomach to in- 
creased activity. This may be accomplished with thermic, chemic, 
electric, and digestive stimuli, among which the last named are the 
most convenient and the most effective, furnishing an idea not only 
of the secretory, but also of the motor and resorptive activity of the 
organ. The analytical results will, however, depend to a large ex- 
tent upon the character of the food ingested, starches and fats exert- 
ing but a slight stimulating effect, while proteids cause a copious se- 
cretion of gastric juice. The ingestion of fluids at the same time 
will likewise influence the results obtained, owing to the dilution of 
the gastric juice. The time of the height of digestion, moreover, 
varies with the kind and quantity of food taken. In order to obtain 
uniform results it is, therefore, necessary to withdraw the gastric 
contents at a certain period after the ingestion of a meal of known 
composition and bulk. 

Numerous test-meals have been proposed. The following are the 
most important : 

The Test-breakfast of Ewald and Boas. 

This consists of from 35 to 70 grammes oi wheat-bread and o^ 
300 to 400 c.c. of water or weak tea, without sugar. It is best to 
give this meal to the patient early in the morning when the stomach 



134 THE GASTRIC JUICE AND GASTRIC CONTENTS. 

is empty — i. e., as a breakfast. The gastric contents are obtained 
one hour later. 

The Test-dinner of Riegel. 

This consists of a plate of soup (400 c.c), a beefsteak (200 
grammes), a slice or two of wheat-bread (50 grammes), and a glass- 
ful of water (200 c.c). The contents of the stomach are obtained 
after four hours. The disadvantage of this method lies in the fact 
that the lumen of the stomach-tube is frequently occluded by large 
pieces of undigested meat, a source of annoyance which may be 
guarded against, however, by making use of finely chopped meat. 

The Double Test-meal of Salzer. 

For breakfast the patient receives 30 grammes of lean, cold roast* 
hashed or cut into strips sufficiently small as not to obstruct the 
stomach-tube, 250 c.c. of milk, 60 grammes of rice, and one soft- 
boiled egg. Exactly four hours later the second meal is taken, con- 
sisting of 35 to 70 grammes of stale wheat-bread and 300 to 400 
c.c. of water. The gastric contents are withdrawn one hour later. 
In this manner the gastric juice is not only obtained at the height of 
digestion, but an idea may at the same time be formed of the motor 
power of the stomach. Under normal conditions the organ should 
contain no remnants of the first meal at the time of examination. 

The Test-breakfast of Boas. 

This consists of a plateful of oatmeal-soup, prepared by boiling 
down to 500 c.c. one litre of water to which one tablespoonful of 
rolled oats has been added. A little salt may be used if desired, 
but nothing more. The contents of the stomach are obtained one 
hour later. This test-meal was devised by Boas in order to guard 
against the introduction from without of lactic acid, which is present 
in all kinds of bread. The meal is employed in doubtful cases of 
cancer of the stomach in which a quantitative estimatiou of lactic 
acid is to be made, the stomach being washed out completely the 
night before. 

Still other test-meals have been suggested, but they do not pos- 
sess any material advantage over those described. 



THE STOMACH-TUBE. 

The stomach-tubes which are now generally in use are essentially 
large ISTelaton catheters. They should measure at least from 72 to 
75 cm. in length, and be provided with three fenestra, of which 
one is placed at the end of the tube and two laterally, as near the 



THE STOMACH-TUBE. 



135 



end as possible. For the purpose of washing out the stomach the 
tube is connected with a glass funnel by means of ordinary rubber 
tubing, which can be detached from the stomach-tube proper. 
There is no advantage in rubber funnels or in having a continuous 
tube. 

It is important that the tubes should be thoroughly cleansed in 
hot water as soon after use as possible. The advice of Boas, more- 
over, to have special, marked tubes for tubercular, syphilitic, and 
carcinomatous patients should be borne in mind. Patients in whom 
lavage is to be practised for any length of time should provide their 
own instruments. 



Contraindications to the Use of the Tube. 

Of direct contraindications to the use of the tube there should be 
mentioned the existence of the various forms of valvular disease 
when in a state of imperfect compensation, angina pectoris, arterio- 
sclerosis of high degree, aneurism of the large arteries, recent hem- 
orrhages from whatever cause, marked emphysema with intense 

bronchitis, acute febrile diseases, etc. 

Fig. 30. 

The Introduction of the Tube. 

The technique of the introduction of the tube 
should be as simple as possible ; the exhibition 
of complicated bottle arrangements for the pur- 
pose of obtaining the gastric juice only adds to 
the excitement of a nervous patient, and should 
be avoided. The patient's clothing and floor 
of the room should be protected from being 
soiled by material that may be vomited along 
the sides of the tube, the dribbling of saliva, 
etc. For this purpose Turck's rubber bib with 
pouch may be advantageously employed. " It 
is so arranged as to form a pouch in front, to 
catch the saliva or stomach contents that may 
be thrown off from the mouth or stomach. A 
detachable tube passes from the bottom of the 
pouch and is conducted into a basin or any 
vessel." ] 

Cocainization of the pharynx is not necessary, 
but may bo resorted to in hypersesthetic in- 
dividuals, a 10-per-cent. solution being em- 
ployed. 

The tube, held like a pen, is introduced to 




Boas' i.uliio.l tub 



1 Manufactured by G. Tiemann «S Co., Now York. 



136 THE GASTRIC JUICE AND GASTRIC CONTENTS. 

the posterior wall of the pharynx, the patient bending his head for- 
ward, and not backward, as is usually advised. The patient is then 
told to swallow, but this is not necessary. The tube is pushed on 
until a resistance is felt, when it meets with the floor of the stomach. 
The entire process does not occupy ten seconds. At the least sign of 
cyanosis, or of marked pallor, the tube should be withdrawn at once 
and the patient observed for a day or two before a second attempt is 
made. 

If the gastric juice does not flow at once, the patient is instructed 
to bear down with his abdominal muscles, and, if this is insufficient, 
to cough a little. Repeated attempts of this kind will usually bring 
about the desired result, unless the tube has not been introduced far 
enough or too far ; in the latter case it will double upon itself, so 
that its end stands above the level of the liquid. Pressing upon the 
abdomen with the hands is of no object. (Method of Expression.) 

Aspiration must at times be employed. For this purpose Boas' 
bulbed tube (Fig. 30) is quite convenient. The manner in which 
it is used is the following : The proximal end of the tube, after hav- 
ing been introduced into the stomach, is compressed and the bulb 
squeezed, when the distal end is clamped and the bulb allowed to 
expand. When this is repeated several times a partial vacuum is 
produced in the tube, which usually causes a flow of gastric juice. 
In the absence of such an instrument the stomach-tube may be con- 
nected with a bottle, in which a partial vacuum has been established 
by aspiration (Fig. 31). Unless the patient is accustomed to the 
introduction of the tube these more complicated procedures should 
be avoided, however, as much as possible. (Method of Aspiration.) 

I have found that in cases in which gastric juice cannot be ob- 
tained by expression the flow may often be started by suction with 
the mouth, and I regard this method as preferable to the one just 
described. With due precautions, viz, holding the tube between the 
fingers near the mouth of the patient, so as to be informed at once, 
by the sense of touch, when the stomach contents have reached this 
point, unpleasant results will be obviated. If only a very small 
amount of gastric juice is present in the stomach — i. e., when a defi- 
nite flow cannot be established — it is best to suck lightly with the 
mouth, to compress the tube firmly, to remove it as rapidly as pos- 
sible, and empty it into a little dish. A few drops sufficient to test 
for free hydrochloric acid can thus always be obtained, even from the 
non-digesting organ. 

Einhorn's bucket-method is of little value, as the amount of gastric 
juice which can thus be obtained is entirely insufficient for analytical 
purposes. It may be employed, however, in patients who are par- 
ticularly nervous and object to the use of the tube, and possibly, also, 
when its use is contraindicated. The test for hydrochloric acid can 



GENERAL CHARACTERISTICS OF THE GASTRIC JUICE. 137 

"be made, but the amount of information which is thereby obtained is 
in itself of comparatively little importance. 

In order to wash out the stomach the funnel-tube is attached, the 
funnel filled with lukewarm water or any desired medicated solution, 
elevated to a height somewhat above the head of the patient, and the 
water allowed to flow. From 500 to 1,000 c.c. may be introduced 
at one time. By suddenly depressing and inverting the funnel over 
.a suitable vessel, before all water has left the funnel, a siphon ar- 
rangement is established and the stomach emptied. It is well to 
measure the returning water as well as the amount introduced. 
Should the flow diminish or cease before all the water has been re- 
moved, the end of the tube probably stands above the level of the 
liquid, and the flow can be started again by pushing the tube on 
further or by withdrawing it a little, as the case may be. 

Fig. 31. 




Arrangement of bottle for the aspiration of the gastric contents. 

Washing out the stomach soon after the ingestion of a full meal is 
always very tedious and annoying if not an impossible procedure, as 
the fenestra readily become obstructed. Should this occur, the 
funnel, filled with water, is elevated as high as possible, with a view 
of overcoming the obstruction by hydrostatic pressure, or, if this 
proves insufficient, the funnel-tube is detached and the obstruction 
dislodged by means of air, for which purpose a Politzer-bag or the 
bulb of a Boas' tube is very convenient. 



GENERAL CHARACTERISTICS OF THE GASTRIC JUICE. 

Pure gastric juice is an almost clear, faintly yellowish fluid, of a 
sour taste and a peculiar characteristic odor. Its specific gravity 
varies between 1.0012 and L.003, corresponding to the presence of 



138 THE GASTRIC JUICE AND GASTRIC CONTENTS. 

but 0. 5 per cent, of solids. Its reaction, owing to the presence of 
hydrochloric acid, is acid. 

Amount. 

Very little is known of the total quantity of gastric juice that is 
secreted in the twenty-four hours. The figure given by Beaumont,. 
viz, 180 grammes pro die, based upon observations made upon the 
often- quoted Canadian hunter, Alexis St. Martin, is undoubtedly too 
low. The amount given by Bidder and Schmidt, viz, that corre- 
sponding to about one-tenth of the body-weight, is probably more 
nearly correct. 1 It may be stated a priori, however, that the quantity 
secreted varies within wide limits, being influenced by numerous 
factors and notably by the degree of the appetite and the amount 
and character of the food taken, especially that of the proteids. 
The age and sex of the individual, the time of clay, notably in its 
relation to the ingestion of food, the emotions, etc., all influence the 
glandular activity of the stomach. 

From the non-digesting organ, as has been pointed out, from 1 to 
60 c.c. of gastric juice may be obtained at one time. The amount 
which can be procured during the process of digestion, on the other 
hand, varies with the amount of liquid ingested, the time of expres- 
sion, the size and motor power of the stomach, and the degree of 
transudation ; the process of resorption probably does not play any 
part, as it has been ascertained that very little water, if any, is ab- 
sorbed in the stomach. 

According to Boas, from 20 to 50 c.c. of filtrate can normally be 
obtained exactly one hour after the ingestion of Ewald's test-break- 
fast. 

Abnormally large quantities of gastric juice are practically only 
found in cases of so-called hypersecretion, the " Magensaftfluss " of 
the Germans, which may occur periodically or continuously. For- 
merly the presence of appreciable quantities of gastric juice in the 
non-digesting organ was regarded as conclusive evidence of the 
existence of this disease, but in the light of Schreiber's researches 
this position can no longer be maintained. The diagnosis should, 
hence, only be made when in conjunction with the clinical symp- 
toms of hypersecretion from 100 to 1,000 c.c. of pure gastric juice 
can be obtained from the non-digesting organ. To this end the 
stomach should be emptied completely by the tube, before retiring, 
and an examination made on the following morning, no food or 
liquids being allowed in the meantime. 

In various pathologic conditions abnormally large quantities of 
liquid may be obtained, which cannot be regarded as gastric juice, 

1 Griinewald' s figure — i. e., 1,580 grammes — I likewise regard as too low. Accord- 
ing to my experience the daily secretion appears to vary between 2,000 and 3,000 c.c. 



CHEMICAL EXAMINATION OF THE GASTRIC JUICE 139 

however. Attention will be drawn to these conditions at another 
place. 

CHEMICAL EXAMINATION OF THE GASTRIC JUICE. 

Chemical Composition of the Gastric Juice. 

As has been briefly shown above the gastric juice consists of water, 
free hydrochloric acid, certain ferments, their zymogens, and mineral 
salts. Analyses giving the exact chemical composition of pure, un- 
contaminated gastric juice in man are still wanting, owing to the 
difficulty of excluding the saliva. In patients, the subjects of gastric 
fistula, analytical studies have, however, been made, and from the 
table below, taken from Schmidt, an idea may be formed of the 
various amounts of solid constituents, contained in 1,000 parts of 
gastric juice, uncontaminated by food or the products of digestion, 
but not free from saliva : 

Water 994.40 

Solids 5.60 

Organic material . . 3.19 

Sodium chloride . . . . . . . . 1.46 

Calcium chloride . 0.06 

Potassium chloride . . . . . . . 0.55 

Ammonium chloride . . . . . . 

Hydrochloric acid . . . . . . . . 0.20 

Calcium phosphate ] 

Magnesium phosphate > . . . . . . 0.12 

Iron phosphate J 

The Acidity of the Gastric Juice is Referable to the 
Presence of Free Hydrochloric Acid. 

It has been conclusively demonstrated by Schmidt that the acidity 
of the gastric juice is due to the presence of free hydrochloric acid. 
After accurately determining the amount of chlorine and all basic 
substances present, it was found that after the latter had been satu- 
rated a quantity of hydrochloric acid still remained, which in the 
dog varied between 0.25 and 0.42 per cent., with an average of 0.33 
per cent. The amount of free acid was also determined by titration 
and the same results reached as by gravimetric analysis. 

While the acidity of pure gastric juice — i. c, gastric juice not con- 
taminated with saliva or food in its various stages of digestion — is 
thus solely due to the presence of free hydrochloric acid, other 
factors enter into consideration in the examination oi' the gastric 
contents during the process of digestion. Acid salts and varying 
amounts of lactic acid derived from the carbohydrates ingested are 
then also found. At the beginning of digestion the acidity, accord- 
ing to Ewald, is due to a certain extent to the presence of lactic 



140 



THE GASTRIC JUICE AND GASTRIC CONTENTS. 



acid. 1 Hydrochloric acid, it is true, is present at the same time, 
bat is held in combination by albuminous material. Later on, 
when the albuminous affinities have become saturated, it appears as 
such, with the result that the formation of lactic acid progressively 



Fig. 32. 



P.M. 

3.0 



2.5 

2.0 

1.5 
1.25 

1.0 
0.75 

0.5 
0.25 







Ml T 




■ - i 


i:iiiiiiiiiiiiiiiiii:iiii|iiiii = |iiiiiiiiiiiii == 




^r i~ 1 1 i % 


U' 1 _ t II T 


1 ! !/p 


/ I i i | ! 1 1 


if t i 1 


/ ' III 


J/T | | 


====2::"-:::i:::z~:=======|==================~ 


"/r ,fr "" "" = ~^^~ N T 




:£jT : T:4:::T: ,:::::+ : =^g:::::: 


t+z _ ^— ^ :: == 3j± === 


1 



10 



20 



30 



40 



50 



70 



80 90 100 



Illustrating the curve of acidity after Ewald's test-breakfast. (Rosenheim.) 

Hydrochloric acid. Lactic acid. X Beginning of the stage of free hydrochloric acid. 

P.M. Pro mille. The numbers upon the abscissa indicate the minutes. 

diminishes, owing to the inhibitory action on the part of the hydro- 
chloric acid upon the lactic-acid-producing organisms. The varying 
degrees of acidity after such test- meals as those of Ewald and 
Eiegel, at different periods of digestion, and the amount of the two 
acids present, may be seen from the accompanying diagrams (Figs. 
32 and 33). 

Under pathologic conditions the amount of free hydrochloric acid, 
as will be shown, may undergo great variations, diminishing on the 
one hand to zero, and increasing on the other to 0.5 per cent., or 
even more. At the same time the amount of lactic acid, which 
normally is present in very small amounts, and is absent altogether 
at the height of digestion, may greatly increase. Fatty acids, more- 
over, which are normally not present in the gastric juice, may then 
also be observed. It is thus seen that the total acidity of the gas- 

1 See Lactic Acid, p. 168. 



CHEMICAL EXAMINATION OF THE GASTRIC JUICE. 141 

trie juice, especially in disease, cannot be regarded as indicating the 
amount of one single acid, unless the absence of other acids and 
acid salts is insured. 

Fig. 33. 



1 




































""" 's 




-sh'' ~~ s * 


^Z< V 




v" 7 5 


2 -y^- ^sr 




J? """*>> 


A *"" ** 


^/ 






/* 


/ '■ ■ H 


10 -/ 1- ~ ~""^'- 




4 2 *"**,. 




_d ' 




0.5 f-j 


7 i 


_r_r 


Iz 


t _ 



30 



60 



00 



120 



150 



180 



J10 240 270 300 



Illustrating the curve of acidity after Riegel's test-breakfast. (Rosenheim. ) 
Hydrochloric acid. Lactic acid. X Beginning of the stage of free hydrochloric acid, 

Method of Determining- the Total Acidity of the Gastric 

Contents. 

To this end a known quantity of gastric juice is r titrated with a 
one-tenth normal solution of sodium hydrate, using phenolphthalein 
as an indicator, when the number of c.c. of the one-tenth normal 
solution employed, multiplied by the equivalent of 1 c.c. of this 
solution in terms of hydrochloric acid, will indicate the amount 
of acid present, from which the percentage-acidity is readily cal- 
culated. 

A normal solution of sodium hydrate is one containing the equiva- 
lent of its molecular weight in grammes — /. c, 40 grammes — in 1 ,000 
c.c. of distilled water; a decinormal solution will, therefore, contain 
4 grammes in the same volume of water. This quantity is dissolved 
in less than 1,000 c.c. and the solution brought to the proper strength 
by titrating it with a solution of oxalic acid of known strength. 

From the equation, 

2NaOH | 0,1 I,( ) 4 ( \.N «,( ), -f- 21 U >. 



142 THE GASTRIC JUICE AND GASTRIC CONTENTS. 

it is seen that two molecules of ISaOH (mol. weight 40) combine 
with one molecule of C 2 H 2 4 -f 2H.,0 (mol. weight 126), or 4 parts 
by weight of the former with 6.3 of the latter. One-tenth gramme 
of oxalic acid would, hence, require 15.873 c.c. of the one-tenth nor- 
mal solution of NaOH for its neutralization, as is apparent from the 
equations : 

6.3 : 1,000 : : 0.1 : x ; 6.3x = 100 and x' = ~ = 15.873. 

D. O 

One-tenth gramme of pure, crystallized oxalic acid is dissolved in 
distilled water, and the solution titrated with the one-tenth normal 
solution of sodium hydrate, which is to be corrected, using two or 
three drops of a 1-per-cent. alcoholic solution of phenolphthalein as 
an indicator, until the rose color of the solution has entirely disap- 
peared ; 15.9 c.c. should bring about this result. As the NaOH 
solution, however, has been purposely made too strong, less will be 
required. The amount of water that must then be added in order to 
bring the solution to its proper strength is determined by the formula 

Nd 
C = — , in which C represents the number of c.c. of water which 

must be added to the remaining solution, N the total number of c.c. 
remaining after one titration, n the number of c.c. consumed in one 
titration, and d the difference between the number of c.c. theoretically 
required and that actually used in one titration. The solution hav- 
ing thus been properly diluted, the correctness of its strength is again 
tested and a further correction made, if necessary, until absolute ac- 
curacy has been attained. 

1,000 c.c. of the one-tenth normal solution containing 4 grammes 
of NaOH are equivalent to 3.65 grammes of HO, as is seen from 
the equation : 

NaOH + HC1 = NaCl + H 2 
40 36.5 

1,000 c.c. of the yq normal solution represent 3.65 grms. of HC1 
100 " " " " " " 0.365 grm. " " 

10 " " " " " " 0.0365 " " " 

1 " " " " " represents 0.00365 " " " 

Application to the gastric juice: 5 or 10 c.c. of the filtered gastric 
juice are titrated with the one-tenth normal solution of sodium hy- 
drate, using two or three drops of a 1-per-cent. alcoholic solution of 
phenolphthalein, as an indicator, until the rose color which appears 
after the addition of every drop of the sodium hydrate solution no 
longer disappears on stirring or becomes deeper after the addition of 
a further drop. The number of c.c. of the one-tenth normal solu- 
tion employed multiplied by 0.00365 will then indicate the acidity 
of the 5 or 10 c.c. of gastric juice in terms of HC1, from which the 
percentage-acidity is calculated. 



CHEMICAL EXAMINATION OF THE GASTRIC JUICE. 143 

Example : 10 c.c. of gastric juice required the addition of 6.5 c.c. 
of the one-tenth normal solution ; 6.5 x 0.00365 (/. <?., 0.0237) would 
hence indicate the acidity of the 10 c.c. of gastric juice in terms of 
HC1, and 0.0237 x 10 = 0.237, the percentage-acidity. 

As these figures only express the amount of HC1 in pure gastric 
juice obtained from normal individuals, it has been found more con- 
venient for clinical purposes to merely indicate the degree of acidity 
by the number of c.c. of the one-tenth normal solution employed. 
In the above example, in which 6.5 c.c. were used, the percentage 
acidity would thus be indicated by the figure 65 ; i. e., the number 
of c.c. of the one-tenth normal solution necessary to neutralize 100 c.c. 
of gastric juice. 

Under normal conditions figures varying from 40 to 60 are usually 
obtained one hour after the ingestion of Ewald's test-breakfast, while 
in pathologic conditions considerable variations are observed. In 
the acute and chronic inflammatory conditions of the stomach, on the 
other hand, as well as in some of the neuroses, the acidity of the gas- 
tric contents is below normal. Higher figures are met with in cases 
of ulcer, in some cases of dilatation, and are especially frequent in 
some of the neuroses, in which a degree of acidity corresponding to 
90 or even more is not infrequently observed. Increased acidity, 
usually associated with hypersecretion of gastric juice, is met with in 
the so-called hyperseeretio acida et continua of Reichmann. 

It has been pointed out that the reaction of normal gastric juice is 
always acid, owing to the presence of free hydrochloric acid, and the 
same may be said to hold good for the gastric contents in general, 
obtained from a normal individual. Pathologically an acid reaction 
is also the rule, as in those cases in which hydrochloric acid is absent, 
fatty acids and lactic acid usually make their appearance. It is, 
therefore, not at all surprising that an alkaline, neutral, or ampho- 
teric reaction is but rarely, or at least not commonly, observed in 
the gastric contents artificially obtained, and practically only seen in 
the so-called mucous form of chronic gastritis, or in those rare cases 
of anadeny, in which a complete destruction of the gastric glands has 
taken place. In vomited material, on the other hand, such observa- 
tions are common, owing to the presence of large amounts of saliva. 
The vomited material in cases of so-called vomitus matutinus, which 
is usually referable to a chronic catarrhal condition of the pharynx, 
generally presents an alkaline reaction, owing to the fact that the 
fluid brought up is largely unchanged saliva. 

The Source of the Hydrochloric Acid. 

That the hydrochloric acid is not directly derived from the chlorides 
ingested is shown by the tact that it is still secreted by starving 
animals. The same point is also proved by the observations of 



144 THE GASTRIC JUICE AND GASTRIC CONTENTS. 

Schreiber, which go to show that the secretion of the acid is con- 
tinuous, not to mention the well-known fact that even after the 
ingestion of material free from chlorine, an acid gastric juice is 
secreted. It is apparent, then, that the chlorides of the blood must 
furnish the necessary chlorine, and as the pyloric glands, which con- 
tain no parietal cells, furnish an alkaline, and the fundus glands, 
which do contain parietal cells, an acid secretion, it is thought that 
these parietal cells are in some manner concerned in the production 
of the hydrochloric acid. The exact manner in which this takes place 
has not been definitely ascertained, but it is not at all improbable 
that the acid results from a " Masseneinwirkung " on the part of the 
carbonic acid, which is present in large quantities in the blood as 
such, upon the sodium chloride, and that, owing to a specific action 
on the part of the parietal cells, the hydrochloric acid is secreted 
into the ducts of the glands of the stomach, while the sodium car- 
bonate which is formed at the same time returns to the blood. 

Two factors are thus necessary in order that a normal amount of 
hydrochloric acid should be secreted — i. e., a normal condition of the 
blood and a normal condition of the cells. Whenever the integrity 
of either of these two factors becomes' impaired it is clear that an 
abnormal secretion of hydrochloric acid or none at all will result. 
The nervous system, furthermore, must be taken into consideration as 
a third factor, as normal innervation is the sine qua non for the normal 
activity of any organ. The secretion of the acid is impaired whenever 
the nutrition of the cells of the stomach suffers, whether this is the 
result of inflammatory lesions, new growths, or hypersemic conditions 
of the stomach, the effect of renal, hepatic, or pulmonary diseases, 
etc., or in consequence of central or peripheral nervous influences. 

In the secondary dyspepsias, then, the result of renal, hepatic r 
cardiac, or hsemic diseases, etc., an examination of the gastric juice 
for free HC1 is of comparatively little value from a diagnostic stand- 
point, although it may suggest valuable points for the dietetic treat- 
ment of such patients. 

Significance of the Free Hydrochloric Acid. 

It was formerly thought that the principal function of the stomach 
was a digestive one, and that in the stomach, owing to the action of 
hydrochloric acid and pepsin, albumins were, to a large extent, trans- 
formed into peptones and albumoses. As pepsin is active only in 
the presence of a free acid, it was thought, moreover, that the power 
of the hydrochloric acid to render pepsin physiologically active con- 
stituted its entire field of usefulness. 

It had already been noted one hundred years ago, however, by the 
Abbe Spalanzani, that pieces of meat immersed in gastric juice re- 
sisted the process of putrefaction for days. When it was shown, 



CHEMICAL EXAMINATION OF THE GASTRIC JUICE. 145 

later on, that the free mineral acids ranked among the most powerful 
antiseptics, and that the stomach secreted an amount of free hydro- 
chloric acid sufficient to prevent the development of most of the 
putrefactive organisms, the time had come to doubt the correctness 
of the view previously held. 

Numerous experiments have been made in order to test the anti- 
septic and germicidal power ■ of the gastric juice. Among the more 
important results achieved the following may be mentioned : The 
comma bacillus of cholera Asiatica is destroyed by the normal acid 
gastric juice, while infection results when this has been previously 
neutralized. The same holds good for numerous other pathogenic 
organisms which are of special interest to the clinician. Among 
these may be mentioned the various species of streptococcus, staphylo- 
coccus pyogenes aureus, the bacillus of anthrax, etc. Unfortunately, 
however, not all species of pathogenic organisms are destroyed by the 
acid of the gastric juice, and the spores of some of those, moreover, 
that are destroyed are possessed of a considerable degree of resistance. 
This is especially true of the tubercle-bacillus and in many cases of 
the spores of the anthrax-bacillus. 

Those bacteria also which cause lactic acid and butyric acid fer- 
mentation resist the anti-fermentative power of the gastric juice to a 
certain extent, as may be concluded from the fact that they are 
always present in the intestines. At the beginning of the process of 
gastric digestion, when the hydrochloric acid secreted is immediately 
taken up by the albuminous bodies which are present, traces of lactic 
acid can usually be demonstrated in the gastric contents, if carbo- 
hydrates have been ingested. Later on, when free hydrochloric acid 
appears, lactic-acid fermentation ceases. This observation is in per- 
fect accord with the fact that the action of the lactic acid producers 
is prevented by the presence of 0.7 p. m. of free hydrochloric acid. 

From what has been said it may be argued that as the principal 
function of the stomach consists in the furnishing of an antiseptic 
and germicidal fluid, under suitable conditions life could go on in 
the absence of the stomach. That this is possible has actually been 
demonstrated by Czerny, who succeeded in removing almost the 
entire organ from a dog. Five or six years later the same animal 
was killed in Lud wig's laboratory, and it was found at the autopsy 
that " near the cardia a small portion of the stomach had remained, 
surrounding a globular cavity tilled with food." This dog then had 
lived for almost six years, practically without a stomach, had gained 
in weight, and was to all intents and purposes as healthy an animal 
as one provided with an entire organ. In the human being similar 
observations have been made on subjects of carcinoma of the stomach. 
It is thus very probable that the stomach, so tar as the process of 
digestion is concerned, is not necessary for the maintenance of life. 
10 



146 THE GASTRIC JUICE AND GASTRIC CONTENTS. 

It has, furthermore, been demonstrated that a deficient secretion 
of hydrochloric acid is noted in all cases in which an increased de- 
gree of intestinal putrefaction occurs, and while indol, phenol, and 
skatol, as well as their compounds with sulphuric acid, in the 
amounts observed in physiologic and pathologic conditions, are not 
thought to exert any toxic influence upon the body, it must be ad- 
mitted that the observations were made upon animals, and that the 
results obtained may not be directly applicable to the human being. 
While a single large dose may not produce symptoms, moreover, it 
is not to be inferred that a continuous intoxication with the products 
of intestinal putrefaction may not lead to decided pathologic results. 

The Amount of Free Hydrochloric Acid. 

Pure gastric juice, according to Ewald, Szabo, and Boas, contains 
from 2 to 3 p. m. of free hydrochloric acid. 

In the digesting organ such amounts are only met with at the 
height of digestion, and after all albuminous and basic affinities 
have been saturated. The time at which free hydrochloric acid can 
be demonstrated in the gastric contents after the ingestion of a meal 
will, hence, vary with the character of the food and its amount. 
When but little work is to be accomplished, free hydrochloric acid 
is found much sooner than otherwise. After Ewald' s test-breakfast, 
for example, it appears after thirty-five minutes ; the point of max- 
imum acidity is reached after from fifty to sixty minutes, and corre- 
sponds to the presence of 1.7 p. m. Following Riegel's meal, on 
the other hand, the free acid appears after 135 minutes and reaches 
its highest point, corresponding to 2.7 p. m., in from 180 to 210 
minutes (Figs. 32 and 33). 

Clinically it is necessary to distinguish between euchlorhydria, or 
the secretion of a normal amount of free hydrochloric acid (0.1 to 
0.2 per cent.), hypochlorhydria, or the secretion of a deficient 
amount (less than 0.1 per cent.), hyperchlorhydria, in which more 
than 0.2 per cent, is found, and, finally, anachlorhydria, in which 
no hydrochloric acid at all is secreted. 

Euchlorhydria. — Euchlorhydria, when associated with clinical 
symptoms pointing to gastric derangement, is most commonly ob- 
served in nervous dyspepsia. A chronic gastritis can always be 
excluded in the presence of a normal amount of the free acid, thus 
constituting a most important point in the differential diagnosis be- 
tween these two conditions. A normal secretion of free hydro- 
chloric acid is, furthermore, observed in some cases of atony or 
hypatony of the muscular walls of the stomach. 

Hypochlorhydria. — Hypochlorhydria is associated with all those 
diseases in which the secretory elements have been more or less 



CHEMICAL EXAMINATION OF THE GASTRIC JUICE. 147 

damaged, as in subacute and chronic gastritis, in some cases of ulcer 
of the stomach or the duodenum, in incipient carcinoma, dilatation, 
and atony. 

Anachlorhydria. — Not many years ago it was thought that the 
absence of free hydrochloric acid from the gastric contents was 
pathognomonic of carcinoma of the stomach. This view was soon 
abandoned, however, as it was shown that cases of carcinoma occur 
in which hydrochloric acid is not only present, but present in excessive 
amounts. This is true especially of those cases in which the malig- 
nant growth has started upon the base of an old ulcer. It was, 
furthermore, shown that anachlorhydria exists in almost all cases of 
advanced chronic gastritis, and is a very common occurrence in 
neurasthenic and hysterical individuals, constituting the so-called 
hysterical anacidity. 

Hyperchlorhydria. — The existence of hyperchlorhydria is gen- 
erally indicative of a gastric neurosis, and is thus frequently met 
with in its simplest form in certain neurasthenic individuals. Asso- 
ciated with a continuous hypersecretion of gastric juice it constitutes 
the neurosis that has been described under the term hyperseeretio 
acida et continua. Hyperchlorhydria is also of frequent occurrence 
in cases of gastric ulcer, and may even occur in carcinoma, notably 
in those cases in which, as has been stated above, the new growth 
has started from an old ulcer. 

Test for Free Acids. 

Following a physical examination of the gastric contents, and, if 
acid, a determination of the total acidity, the next step will be to 
determine whether or not the acid reaction is referable to the presence 
of a free acid, of combined acids, or of acid salts. 

The Congo-red Test. — Congo-red is a carmin-colored powder, 
while its solutions are of a peach- or brownish-red color, which 
changes to azure-blue upon the addition of a free acid, but remains 
unaffected in the presence of an acid salt. Congo-red may be em- 
ployed in solution or in the form of a test-paper. The latter, how- 
ever, is less delicate than the solution, and only indicates the pres- 
ence of 0.01 per cent, of hydrochloric acid, while a positive reaction 
can still be obtained with the aqueous solution in the presence of 
0.0009 per cent. The solution should be moderately dilute. The 
test-paper is prepared by soaking filter-paper, free from ash, in this 
solution, drying and cutting it into suitable strips. In order to test 
for the presence of a free acid it is only necessary to immerse a strip 
of the test-paper in the filtered gastric juice, or to add a drop or two 
of the solution to a small amount of the juice, when in the presence 
of a free acid a blue color will develop, which varies from a sky-blue 
to a dee}) azure according to the amount present. 



148 THE GASTRIC JUICE AND GASTRIC CONTEXTS. 

A negative result will at once exclude the possibility of peptic 
activity, as pepsin only acts in solutions containing a free acid. 

If the result of the test is positive, the nature of the free acid must 
still be ascertained, and it is, therefore, necessary to test for free hydro- 
chloric acid, or in its absence for lactic acid and certain fatty acids. 

Tests for Free Hydrochloric Acid. 

The various reagents which may be employed are given below, 
and are arranged according to their degree of delicacy, viz : 

1. Dimethyl-amido-azo-benzol . . . . . 0.02 p.m. 

2. Phloroglucin-vanillin . . . . . 0.05 " 

3. Kesorcin 0.05 " 

4. Methyl-violet 0.2 . " 

5. Tropa?olin 00 0.3 " 

6. Emerald-green 0.4 " 

7. Mohr's reagent . . . . . . 1.0 " 

The Dimethyl-amido-azo-benzol Test. — This test is also known 
as Topfer's test and is destined to replace the older phloroglucin- 
vanillin and resorcin tests in the clinical laboratory. The delicacy 
of the reagent is such that the neutral yellow color of the indicator 
is changed to a reddish tinge upon the addition of but one drop of a 
one-tenth normal solution of hydrochloric acid in 5 c.c. of distilled 
water. Organic acids yield a red color only when present in amounts 
exceeding 0.5 per cent.; but even then a negative reaction is obtained, 
if, as in the stomach, small quantities of albumins, peptones, or mucin 
are at the same time present. A positive reaction is then only ob- 
tained when the organic acids are present in amounts far exceeding 
0.5 per cent. Loosely combined hydrochloric acid and acid salts do 
not produce this change in color. Its superior delicacy, as compared 
with the phloroglucin-vanillin and resorcin tests, is apparent from the 
fact that 5 c.c. of an 0.5-per-cent. solution of egg-albumin, to which 
six drops of a one-tenth normal solution of hydrochloric acid have 
been added, still give a positive reaction with dimethyl-amido-azo- 
benzol, while the phloroglucin-vanillin and resorcin reactions are 
negative. 

For practical purposes a 0.5-per-cent. alcoholic solution is em- 
ployed. One or two drops of this are added to a trace of the gastric 
contents, which need not be filtered : in the presence of free hydro- 
chloric acid a beautiful cherry-red color develops, which varies in 
intensity according to the amount of free acid present. A test-paper, 
prepared by soaking strips of filter-paper in the 0.5-per-cent. solu- 
tion and allowing them to dry, may also be employed. With gastric 
juice containing no free hydrochloric acid, as with distilled water, a 
yellow color results, the fluid at the same time becoming cloudy and 
beautifully fluorescent. 



CHEMICAL EXAMINATION OF THE GASTRIC JUICE. 149 

I have personally used Topfer's test during the last eight years 
and prefer it to all others. 

The Phloroglucin-vanillin Test. — The solution employed con- 
tains 2 grammes of phloroglucin and 1 gramme of vanillin, dissolved 
in 30 c.c. of absolute alcohol : a yellow color results, which gradually 
turns a dark golden-red, changing to brown when exposed to the 
light. The solution should, therefore, be kept in a dark-colored 
bottle. Lenhartz suggests the use of separate solutions of phlo- 
roglucin and vanillin, one or two drops of each being employed in 
the test. Boas recommends a solution of the phloroglucin and 
vanillin, in the proportions indicated, in 100 grammes of 80-per-cent. 
alcohol, and claims that the reagent is then still more sensitive and 
more stable. If a few drops of gastric juice, or even of the unfiltered 
gastric contents, containing 0.05 or more per cent, of free hydro- 
chloric acid, are treated with the same number of drops of the 
reagent, no change in color results, but upon the application of gen- 
tle heat — boiling and rapid evaporation are to be avoided — a rose-tint 
or exceedingly fine rose-colored lines develop, which are characteristic 
of the presence of the free acid. 

For practical purposes it is best to carry on this slow evaporation 
on a thin porcelain butter-dish, the porcelain cover of a crucible, or 
in a small evaporating-dish of the same material. The color obtained 
in the presence of free hydrochloric acid is a rose color in every in- 
stance and varies in intensity with the amount of acid present. A 
brown,, brownish-yellow, or brownish-red color always indicates that 
excessive heat has been applied or that free hydrochloric acid is 
absent. 

Organic acids do not produce the reaction, nor is it interfered with 
by their presence, or that of albumins, peptones, or acid salts. 

A phloroglucin-vanillin test-paper, prepared by soaking strips of 
filter-paper, free from ash, in the solution and drying them, may 
also be employed. If a strip of this is moistened with a drop of 
gastric juice and gently heated in a porcelain dish, the rose color 
will be seen to develop in the presence of free hydrochloric acid, and 
does not disappear upon the addition of ether. 

The Resorcin Test. — The solution consists of five grammes of 
resublimed resorcin and 3 grammes of cane-sugar, dissolved in 100 
grammes of 94-per-ccnt. alcohol. It is of equal delicacy as the 
phloroglucin-vanillin solution and has t\w advantage of greater sta- 
bility. 

Five or six drops of gastric juice are treated with three to the 
drops of the reagent and slowly evaporated to complete dryness, 
over a small flame, when a beautiful rose- or vermilion-red mirror 
will bo obtained, which gradually fades on cooling. It' the reagent 
is employed in the form of a test-paper, a violet color at first do- 



150 THE GASTRIC JUICE AND GASTRIC CONTENTS. 

velops, which upon the application of heat turns brick-red and does 
not disappear on treatment with ether. 

The presence of acid salts, organic acids, albumins, or peptones 
does not interfere with the reaction. 

The Methyl-violet and Emerald-green Tests cannot be recom- 
mended, as they are uncertain and may lead to error. 

The Tropaeolin Test. — Tropseolin 00, when employed according 
to the method suggested by Boas, is a very reliable reagent, indicat- 
ing the presence of 0.2 to 0.3 per cent, of free hydrochloric acid. 
Three or four drops of a saturated alcoholic solution of tropaeolin 
00, which has a brownish-yellow color, are placed in a small porce- 
lain dish or cover, and allowed to spread over the surface. A like 
amount of gastric juice is then added and likewise allowed to flow 
over the surface of the dish ; upon the application of gentle heat 
beautiful lilac or blue stripes appear, which are said to be absolutely 
characteristic of free hydrochloric acid. 

A tropseolin test-paper may also be prepared, by soaking filter- 
paper, free from ash, in the alcoholic solution, and then drying 
and cutting it into strips. A few drops of gastric juice contain- 
ing free hydrochloric acid produce a more or less pronounced 
brown color upon this paper, which turns lilac or blue upon the ap- 
plication of gentle heat. Organic acids, when present in large 
amounts, likewise produce a brown color, but this disappears on 
heating, and a lilac or blue color does not result. 

For ordinary purposes this test is sufficient, and recourse need 
only be had to the more delicate reagents, when a negative or a 
doubtful result is obtained. 

Mohr's Test, as Modified by Ewald. — Two c.c. of a 10-per-cent. 
solution of potassium sulphocyanide are treated with 0.5 c.c. of a 
neutral solution of ferric acetate, and diluted to 10 c.c. with distilled 
water, a ruby-red solution resulting. Of this a few drops are placed 
in a porcelain dish, w r hen a drop or two of the filtered gastric con- 
tents are allowed to come into contact with the reagent. In the 
presence of free hydrochloric acid a light violet color develops at the 
point of contact between the two fluids, and turns a deep mahogany 
brown upon mixiug. 

The test is not interfered with by the presence of acid salts or 
peptones, but is not so sensitive as those described. 

The Benzopurpurin Test. — Benzopurpurin 6B has been highly 
recommended by v. Jakseh as a very sensitive test for hydrochloric 
acid. It is best used in the form of a test-paper, prepared by soak- 
ing strips of filter-paper, free from mineral ash, in a concentrated 
watery solution of the reagent and allowing them to dry. 

In the presence of more than 0.4 gramme of hydrochloric acid in 
100 c.c. of gastric juice the dark-red color of the test-paper immedi- 



CHEMICAL EXAMINATION OF THE GASTRIC JUICE. 151 

ately turns a deep blackish-blue. Should a brownish-black color 
develop, this is likely due to the presence of organic acids, or a mix- 
ture of these and hydrochloric acid. If the color is caused by or- 
ganic acids only, it will disappear on washing the strip with a little 
neutral ether, the original color of the test-paper being thus restored ; 
but if due to a mixture of the two, the reaction is less marked, 
and does not disappear. According to Hellstrom, 0.39 milligramme 
of hydrochloric acid dissolved in 6 c.c. of water, can be recognized 
by the addition of only 5 milligrammes of benzopurpurin. 

Acid salts, peptones, and serum-albumin do not seriously inter- 
fere with the reaction. 

Benzopurpurin test-paper v. Jaksch claims to be more sensitive 
than the Congo-red paper. 

The Combined Hydrochloric Acid. 

It has been stated (see p. 139) that the total acidity of the gastric 
juice can only be referred to hydrochloric acid, when organic acids 
and acid salts are absent. At the same time the free acid is titrated 
together with the loosely combined. The presence of free hydro- 
chloric acid in normal amounts implies, of course, the existence of 
peptic activity, and indicates that all albuminous affinites have been 
saturated. In the absence of free hydrochloric acid, however, it is 
important to know whether or not hydrochloric acid is secreted — i. <?., 
whether peptic digestion is at a standstill or whether an amount is 
secreted that is only sufficient to saturate certain albuminous affinities 
without appearing in the free state. In the treatment of the various 
forms of gastric disease, more especially those associated with an 
absence of free hydrochloric acid, accurate knowledge in this respect 
is important. If no hydrochloric acid at all is secreted, the stomach 
can only be regarded as a storehouse, as it were, and proteids must 
be ordered in such form that they may be subjected to the process of 
pancreatic digestion with as little delay as possible, the nutrition of 
the body being aided, if necessary, by a suitable administration of 
predigested food. If, on the other hand, an amount of hydrochloric 
acid is secreted which is sufficient to saturate the albuminous affinities 
of an ordinary meal, or at least of moderate amounts of proteids, the 
dietetic directions need not be so stringent. While in the former 
case the absence of loosely combined hydrochloric acid usually indi- 
cates complete destruction of the glandular elements of the stomach — 
in other words, an irreparable condition — a fair prognosis may be 
given when the amount of acid secreted is sufficient tor the saturation 
of the albuminous affinities of an ordinary meal. The following 
table 1 shows the amount of hydrochloric' acid necessary to saturate 

1 Taken from Ehrlich: Dissert. Erlangen, 1893. 



152 THE GASTRIC JUICE AND GASTRIC CONTENTS. 

the affinities of known quantities of various articles of food, the figures 
given having reference to 100 c.c. or 100 grammes : 

Milk 0.32-0.42 gramme of pure HC1. 

Beef (boiled) . . . . .2.0 grammes " " 

Mutton (boiled) . . . .1.9 

Veal (boiled) 2.2 

Pork (boiled) . 1.6 

Sweetbread (boiled) . . . .0.9 gramme " " 

Calves' brain (boiled) . . . 0.65 " " " 

Ham (raw) . . . . .1.9 grammes " " 

Ham (boiled) 1.8 " 

Liver sausage . . . . .0.8 gramme " 
Cervelat sausage . . . .1.1 grammes " " 

Mettwurst . . . . .1.0 gramme " " 

Blood sausage . . . . .0.3 " " " 

Grabam bread 0.3 " 

Pumpernickel 0.7 

Wheat bread 0.3 " 

Rye bread 0.5 " 

Swiss cheese . . . . .2.6 grammes " " 

Fromage de Brie . . . .1.3 " " " 

Edam cheese ..... 1.4 " " " 

Roquefort cheese . . . .2.1 " " " 

Beer (German) . . . 0.07-0.15 gramme " " 



The Quantitative Estimation of the Hydrochloric Acid of the 

Gastric Juice. 

. Tbpfer's Method. — The free and combined hydrochloric acid is 
most conveniently estimated according to Topfer's method, which is 
both simple and sufficiently accurate for clinical purposes. 

In this method the total acidity (a) of a given amount of gastric 
juice — i. e., the acidity referable to the presence of free hydrochloric 
acid, combined hydrochloric acid, acid salts, and any organic acids 
that may be present — is first determined (lactic acid and the fatty 
acids, if present, need not be removed), using phenolphthalein as an 
indicator. This is followed by a determination of the acidity refer- 
able to free acids and acid salts in the same amount of gastric juice 
(6), using alizarin (alizarin monosulphonate of sodium) as an indi- 
cator. As this does not react with loosely combined hydrochloric 
acid, the difference between "a" and "6" will indicate the amount 
of the latter. The free hydrochloric acid (c) finally is estimated with 
dimethyl-amido-azo-benzol as an indicator, the difference between a 
and b -f c giving the acidity referable to organic acids and acid salts. 

The solutions required are the following : 

1. A decinormal solution of sodium hydrate. 

2. A 1-per-cent. alcoholic solution of phenolphthalein. 

3. A 1-per-cent. aqueous solution of alizarin. 

4. An 0.5-per-cent. alcoholic solution of dimethyl-amido-azo- 
benzol. 



CHEMICAL EXAMINATION OF THE GASTRIC JUICE. 153 

Three separate portions of 5 or 10 c.c. of filtered gastric juice are 
measured off into three small beakers or porcelain dishes. To the 
first portion one or two drops of phenolphthalein are added, when 
it is titrated with the one-tenth normal solution of sodium hydrate. 
It is necessary, however, to titrate to the point of a deep red, and 
not to the rose hue which first appears. It will be seen that upon 
the addition of the first few drops of the one-tenth normal solution 
the red color, which first appears, disappears on stirring. Upon 
further titration a point is reached when this no longer occurs, and 
the color of the entire solution suddenly turns to a rose. This rose 
color, however, is not the end-reaction that is to be obtained. If the 
titration is continued, it will be observed that a dark-red cloud forms 
in the light rose-colored solution, which disappears on stirring ; finally 
a point is reached when an additional drop no longer intensifies the 
color of the solution. This point is the end reaction which must be 
obtained. 

To the second portion three or four drops of the alizarin solution 
are added, when it also is titrated with the one-tenth normal solution 
of sodium hydrate, until a pure violet-color is obtained. As some 
little practice is required in order to determine this point with accu- 
racy, Topfer advises to previously make the following simple tests : 

1. To 5 c.c. of distilled water add 2 or 3 drops of alizarin solu- 
tion, when a yellow color will result. 

2. To 5 c.c. of a 1-per-cent. solution of disodium phosphate add 
the same number of drops, when a red or slightly violet color will 
be obtained. 

3. Five c.c. of a 1-per-cent. solution of sodium carbonate, treated 
with 2 or 3 drops of the alizarin solution will strike a pure violet ; 
this is the color to which the titration must be carried. 

In the third portion of the gastric juice the free hydrochloric acid 
is titrated, after the addition of three or four drops of the dimethyl- 
amido-azo-benzol, until the last trace of red — in the presence of free 
hydrochloric acid — has disappeared. A yellow color resulting upon 
the addition of the indicator demonstrates the absence of the free 
acid, as has been shown on page 148. The results are then calculated 
as shown in the following example. 

Ten c.c. of gastric juice, using phenolphthalein as an indicator, 
required 10 c.c. of the one-tenth normal solution in order to bring 
about the end reaction, while a like amount titrated in the same 
manner with alizarin required 7 c.c. in order to bring about the 
same result. The difference between 10 and 7 — L <■., 3 — would 
thus indicate the number of c.c. necessary to neutralize the amount 
of hydrochloric acid in combination with albuminous material. As 
1 c.c. of the one-tenth normal solution represents 0.00365 gramme 
of hydrochloric acid, the amount of the acid thus held will be equiv- 



154 THE GASTRIC JUICE AND GASTRIC CONTENTS. 

alent to 0.00365x3 = 0.01095 gramme of hydrochloric acid; 
i. e., 0.1095 per cent. 

In the estimation of the free hydrochloric acid 3.2 c.c. of the one- 
tenth normal solution were required, using dimethyl-amido-azo-ben- 
zol as an indicator; this would correspond to 0.00365 x 3.2 ; i. <?., 
0.1168 per cent. The value of the total acidity in terms of hydro- 
chloric acid is 10 x 0.00365 = 0.0365 gramme for every 10 c.c. of 
gastric juice, or 0.365 per cent. By deducting the amount of the 
free and combined hydrochloric acid, viz, 0.1095 -f 0.1168 = 0.2263, 
from this it is found that the acidity of the gastric juice referable to 
organic acids and acid salts amounts to 0.1387 per cent., so that the 
results can be tabulated as follows : 

Free hydrochloric acid 0.1168 per cent. 

Combined hydrochloric acid .... 0.1095 " 
Organic acids and acid salts .... 0.1387 



Total acidity .... 0.3650 per cent. 

The Method of Martius and Liittke (Modified). — This method 
is equally exact, but requires a greater expenditure of time. 

It is based upon the fact that upon incineration of the gastric 
juice the free hydrochloric acid and that loosely combined with al- 
buminous material escape, while the chlorine in combination with 
inorganic bases remains in the mineral ash, unless a very intense 
heat is applied for some time. By subtracting the amount of chlorine 
present in the latter form from the total amount, the quantity in 
combination with albuminous material and that occurring as free 
acid will be found. The total acidity of the gastric juice is then de- 
termined, and that referable to the presence of the free and com- 
bined hydrochloric acid subtracted, the difference giving the amount 
of organic acids present. By determining the acidity due to the 
presence of free hydrochloric acid according to Topfer's method, 
and deducting the amount found from that referable to the presence 
of free and combined hydrochloric acid, the amount of the latter is 
obtained. 

Reagents required : 

1. A solution of nitrate of silver in nitric acid of such a strength 
that 1 c.c. shall represent 0.00365 gramme of hydrochloric acid. 

2. Liquor ferri sulphur, oxydati. 

3. A decinormal solution of ammonium sulphocyanide. 

4. A one-tenth normal solution of sodium hydrate. 

5. A 1-per-cent. alcoholic solution of phenolphthalein. 

6. A 0.5-per-cent. alcoholic solution of dimethyl-amido-azo-benzol. 
Preparation of the solutions : 

1. The silver nitrate solution : As a solution is required of such 
strength that 1 c.c. shall be equivalent to 0.00365 gramme of hydro- 



CHEMICAL EXAMINATION OF THE GASTRIC JUICE. 155 

chloric acid, the amount of silver nitrate that must be dissolved in 
1,000 c.c. of water is ascertained in the following manner : Since 
169.66 (molecular weight) parts by weight of silver nitrate combine 
with 36.5 parts of hydrochloric acid (molecular weight), the amount 
of silver nitrate required for each c.c. is found from the equation : 

169.66:36.5: :x: 0.00365; 36.5 x =0.6192590 ; x = 0.0169. 

In one c.c. of the silver solution 0.0169 gramme of silver nitrate must 
thus be present, or 16.9 grammes in the litre. This quantity, or 
roughly 17 grammes, is weighed off and dissolved in 900 c.c. of a 
25-per-cent. solution of nitric acid ; as the acid must be present in 
excess, the solution is purposely made too strong. To this solution 
50 c.c. of the liquor ferri sulphurati oxydati are added. The solu- 
tion is then brought to the proper strength by titration of a known 
number of c.c. of a one-tenth normal solution of hydrochloric acid 
and correcting as usual. 

2. The ammonium sulphocyanide solution : A normal solution of 
ammonium sulphocyanide contains 75.98 grammes (molecular weight) 
per litre, and a decinormal solution 7.598 grammes. This quantity, 
or roughly 8 grammes, is dissolved in about 900 c.c. of water and 
the solution brought to the proper strength by titrating a known 
number of c.c. of the silver nitrate solution, when every c.c. should 
correspond to 1 c.c. of the silver solution, i. e., to 0.00365 gramme 
of hydrochloric acid. It is corrected as described elsewhere. 

Method : 

1. To determine the total amount of chlorine present : 10 c.c. of 
filtered gastric juice — Martius and Liittke make use of the unfiltered 
gastric contents — are measured off into a small flask bearing a 100 
c.c. mark, and treated with an excess of the one-tenth normal solu- 
tion of silver nitrate. Experience has shown that 20 c.c. are suffi- 
cient. The mixture is agitated and allowed to stand for ten minutes. 
Distilled water is then added to the 100 c.c. mark ; the mixture is 
agitated once more and filtered through a dry filter into a dry beaker. 
Fifty c.c. of the filtrate are titrated with the one-tenth normal solu- 
tion of ammonium sulphocyanide until the blood-red color which ap- 
pears upon the addition of every drop — due to the formation of ferric 
sulphocyanide — no longer disappears on stirring. By multiplying 
the number of c.c. of the ammonium sulphocyanide solution used by 
2 (the number of c.c. that would have been necessary for the precip- 
itation of the excess of silver in 100 c.c.) and deducting the result 
from the number of c.c. of the one-tenth normal solution of silver 
nitrate employed, viz, 20, the number of c.c. of the latter solution is 
found which was necessary to precipitate the chlorine in 10 v.c. of the 
gastric juice. As 1 c.c. of the solution represents 0.0036 gramme 
of hydrochloric acid, it is only accessary to multiply this figure by 



156 THE GASTRIC JUICE AND GASTRIC CONTENTS. 

the number of c.c. used in the precipitation of the chlorine. The 
resulting value, "T," expresses the total amount of chlorine present. 
As a general rule, it is not necessary to decolorize the gastric 
juice. If desired, however, 5 to 15 drops of a 5-per-cent. solution 
of potassium permanganate may be added to the 10 c.c. employed, 
after the mixture has stood for ten minutes. 

2. Determination of the amount of chlorine in combination with 
inorganic bases, "F." Ten c.c. of the filtered gastric juice are care- 
fully evaporated to dryness in a platinum crucible, on a water-bath 
or upon a plate of asbestos, in order to avoid sputtering (as the heat 
applied in the process of incineration is not very intense, a porcelain 
crucible may also be employed). The residue is then carefully in- 
cinerated over the open flame, the process being only carried to the 
point when the organic ash no longer burns with a luminous flame. 
Intense heat should be avoided, as the chlorides are volatilized upon 
the application of red heat. On cooling the ash is moistened with a 
few drops of distilled water and mixed with a stirring-rod, when the 
residue is extracted in separate portions with 100 c.c. of hot, dis- 
tilled water and filtered. This amount is usually sufficient to dis- 
solve all the chlorides present. If any doubt should exist, however, 
it is only necessary to add a drop of the silver solution to a few drops 
of the last portion of the filtrate : the formation of a cloud, referable 
to silver chloride, will necessitate still further washing. The whole 
filtrate is then treated with 10 c.c. of the one-tenth normal solution 
of silver nitrate, and the amount consumed in the precipitation of 
the chlorides determined by titration with the one-tenth normal so- 
lution of ammonium sulphocyanide, as described above. The hy- 
drochloric acid present in combination with inorganic bases is thus 
determined. The difference between the amount of hydrochloric 
acid in combination with inorganic bases and the total amount of 
chlorine in terms of hydrochloric acid will then indicate the amounts 
of the free and of the combined hydrochloric acid, which are termed 
" L " and " C," respectively .; hence T - F = L + C. 

3. The total acidity in terms of hydrochloric acid is further de- 
termined according to the method given elsewhere (see p. 141) and 
indicated by the letter " A." The difference between the total acid- 
ity and the amount of free and combined hydrochloric acid will 
represent the amount of organic acids and acid salts, " O " ; hence 
= A-(L+C). 

The free hydrochloric acid finally is determined according to the 
method of Topfer. The difference between the value thus found 
and that expressing the amount of free and combined hydrochloric 
acid will indicate the amount of the latter ; hence (L -j- C) — L = C. 

Leo's Method. — This method is based upon the observation that 
calcium carbonate combines with free and combined hydrochloric acid 



CHEMICAL EXAMINATION OF THE GASTRIC JUICE. 157 

at ordinary temperatures to form neutral calcium chloride, while the 
acid phosphates are not affected. It is thus clear that by determin- 
ing the total acidity of the gastric juice, and deducting from this 
the acidity referable to acid salts, the amount of the physiologically 
active hydrochloric acid — i. e., of the free and Combined hydrochloric 
acid — is obtained. 

As it has been shown that in the presence of calcium chloride 
(formed, as indicated above, upon the addition of calcium carbonate), 
owing to the formation of calcium monophosphate — CaHP0 4 , twice 
the quantity of sodium hydrate is taken up by the same quantity of 
diacid salt, it is necessary to titrate after the addition of an excess of 
calcium chloride. 

Reagents required : 

1. A one-tenth normal solution of sodium hydrate. 

2. A 1-per-cent. alcoholic solution of phenolphthalein. 

3. A concentrated solution of calcium chloride. 

4. Chemically pure calcium carbonate. The purity of the salt 
may be tested by stirring a small piece with water ; the solution 
should not color red litmus-paper blue. A solution of the salt in 
dilute hydrochloric acid should not yield a precipitate when treated 
with sulphuric acid. 

Method : Organic acids that may be present are first removed by 
shaking with ether, 50 to 100 c.c. being required for every 10 c.c. 
of gastric juice. The total acidity of the gastric juice is then de- 
termined in 10 c.c. of the filtered liquid after the addition of 5 c.c. 
of the concentrated solution of calcium chloride, the result being 
termed " A.' 7 

The acidity referable to the presence of acid phosphates is deter- 
mined as follows : 15 c.c. of filtered gastric juice are treated with a 
pinch of dry and chemically pure calcium carbonate ; the mixture is 
thoroughly stirred, and passed at once through a dry filter. Ten 
c.c. of the filtrate, from which the carbon dioxide formed is expelled 
by means of a current of air, are then treated with 5 c.c. of the 
calcium chloride solution and titrated as above, the resulting value 
being termed " P." A — P is hence equivalent to L -f C. The 
value of " C " can then be ascertained by determining the acidity 
referable to free hydrochloric acid according to Topfer's method, ami 
deducting the value found from L -f C. 

This method is sufficiently accurate for practical purposes, ami has 
the advantage of not requiring the expenditure of much time. 

The Ferments of the Gastric Juice and their Zymogens. 

Pepsin and Pepsinogen. — According to our present view, the 
zymogen of pepsin, viz, pepsinogen or propepsin, and not pepsin it- 



158 THE GASTRIC JUICE AND GASTRIC CONTENTS. 

self, is secreted by the chief cells of the fundus glands. This is based 
upon the observation that an aqueous extract of the mucous mem- 
brane of the stomach of a fasting animal, recently killed, does not 
loose its digesting power, for a considerable length of time, when 
treated with a 1-per-cent. solution of sodium carbonate, at a tempera- 
ture of from 38° to 40° C, whereas pepsin itself is thus rapidly de- 
stroyed. It is natural then to conclude that the glands of the 
stomach do not contain pepsin, but some other substance during the 
process of fasting, which is capable of resisting the action of sodium 
carbonate, and which can be transformed into pepsin by the addition 
of hydrochloric acid. This substance has been termed pepsinogen or 
propepsin. As a rule, pepsin is only obtained from the mucous 
membrane of the digesting organ, while at other times the physio- 
logically inactive zymogen is found. As the zymogen, moreover, is 
probably always present together Avith pepsin in the gastric jnice 
obtained from healthy individuals during the process of digestion, it 
is not clear whether the transformation of the zymogen into its fer- 
ment takes place in the body of the cell or after secretion. There is 
evidence to show, however, that the latter view is correct. 

This is not the place to enter into a detailed consideration of the 
various properties of pepsin, and it will suffice to say that the activity 
of the ferment is destroyed by even very dilute solutions of the 
alkaline carbonates. The same result is reached by exposing a watery 
solution of pepsin to a temperature of 70° C, while in its dry state 
a temperature of 100° C. will not destroy its activity ; this is shown 
by the fact that a specimen of pepsin thus treated is, on cooling, still 
capable of digesting albumins in the presence of hydrochloric acid. 

While pepsin is capable of digesting albumins in the presence of 
other acids, viz, phosphoric, sulphuric, oxalic, acetic, lactic, and 
salicylic acid, the solutions must be stronger than in the case of 
hydrochloric acid. With lactic acid, for example, a satisfactory 
result is only reached with a concentration of from 12 to 18 p. m., 
while of hydrochloric acid 2 to 4 p. m. are sufficient. Larger or 
smaller amounts do not act so promptly. 

Very important from a practical standpoint is the fact that but 
small quantities of pepsin are required to digest large amounts of 
albumin. Petit thus claims that a pepsin preparation from his own 
laboratory was capable of dissolving 500,000 times its weight of 
fibrin in seven hours. This property on the part of pepsin of doing 
an amount of work that is entirely out of proportion to the amount 
of ferment present, is common to all ferments, and is dependent upon 
the fact that the ferment itself undergoes no change during the 
process. 

Exact figures, expressing the quantity of pepsin or of its zymogen 
produced in the twenty-four hours are lacking, and inferences can 



CHEMICAL EXAMINATION OF THE GASTRIC JUICE. 159 

hence only be drawn as to the physiologic activity of the ferment 
from the rapidity with which given amounts of albuminous material 
are digested. This, however, depends to a large extent upon the 
nature and the concentration of the free acid present. Under normal 
conditions 25 c.c. of gastric juice will dissolve 0.05 to 0.06 gramme 
of serum-albumin in one hour, the same amount of coagulated egg- 
albumin in three hours, and a like amount of fibrin in one hour and 
a half. 

As abnormalities in the circulation and innervation of the stomach 
apparently do not influence the production of pepsin, or rather of its 
zymogen, a diminution in the degree of peptic activity, or its total 
absence, may be referred directly to disease of the stomach itself, 
viz, its glandular apparatus. The determination of the presence or 
absence and relative amount of pepsin in the gastric juice, hence, 
furnishes more useful information than the recognition of the pres- 
ence or absence of free hydrochloric acid. 

As pepsin is formed from pepsinogen through the agency of a 
free acid, notably of hydrochloric acid, its presence, in the absence 
of organic acids, in notable quantities, at once indicates the presence 
of hydrochloric acid. It may be said, vice versa, that if free hydro- 
chloric acid is present in the gastric juice, and the latter digests albu- 
mins, pepsin also will be found. Should the zymogen alone be 
present digestion will only take place upon the addition of an acid, 
while an entire absence of digestion upon the addition of hydro- 
chloric acid indicates the absence of both pepsin and its zymogen. 
At times, though rarely, a " gastric juice " is met with, which is 
capable of digesting albumin in the absence of hydrochloric acid, 
owing to the presence of pancreatic juice — a point which is im- 
portant, both from a diagnostic and a prognostic point of view. 

In the differential diagnosis of a chronic gastritis and a neurosis, 
or a dyspeptic condition referable to hyperemia of the gastric mu- 
cous membrane, the demonstration of the presence of the zymogen 
in the absence of hydrochloric acid may, at times, be very impor- 
tant, bearing in mind the fact that circulatory and nervous disturb- 
ances apparently do not influence the production of pepsinogen. 
An entire absence of the latter would, of course, warrant the diag- 
nosis of complete anadeny of the stomach. 

Tests for Pepsin and Pepsinogen. — Test for the enzyme : If the 
presence of free hydrochloric acid has been previously ascertained, 
25 c.c. of filtered gastric juice are set aside and kept at a tempera- 
ture of from 37° to 40° C, a bit of coagulated egg-albumin, fibrin, 
or serum-albumin being added. In order to permit of a comparison 
of results the same amounts should always be taken ; 0.05 to 0.06 
gramme of egg-albumin, as has been shown, ought, under physio- 
logic conditions, to be digested in three hours. 



160 THE GASTRIC JUICE AND GASTRIC CONTENTS. 

Test for the Zymogen. — Should hydrochloric acid be absent the test 
is made in the same manner, after the addition of from 3 to 5 drops 
of the officinal solution of hydrochloric acid to 25 c.c. of the filtrate. 
Under such conditions pepsinogen alone is usually found. 

Quantitative Estimation. — Of pepsin : Accurate methods for 
the quantitative estimation of pepsin do not exist, and relative 
values only can be obtained. Most convenient is the method sug- 
gested by Hammerschlag : Three Esbach's tubes (albuminimeters) 
are employed. Tube A is filled to the mark U with a mixture of 
10 c.c. of a 1-per-cent. solution of serum-albumin in 0.4 per cent, 
of hydrochloric acid, and 5 c.c. of filtered gastric juice. The second 
tube, B, which is the standard, is likewise filled to the mark U, but 
0.5 gramme of pepsin is added to the serum solution, instead of the 
gastric juice. The third tube, C, merely contains a mixture of the 
serum solution and 5 c.c. of water. After having been kept in the 
thermostat for one hour, at a temperature of 37° C, Esbach's 
reagent is added to each tube to the mark R. After standing for 
twenty-four hours the amount of precipitated albumin is read off, 
and the difference between that in A and C compared with that in B. 

Of Pepsinogen : In order to estimate the amount of pepsinogen 
the method of Boas may be employed. To this end the gastric juice 
is diluted with distilled water in varying proportions, such as 1:5, 
1 : 10, 1 : 20, etc. A known quantity of coagulated albumin is added 
to each specimen, as also one or two drops of an officinal solution of 
hydrochloric acid, for every 10 c.c. employed. These tubes are kept 
at a temperature of from 37° to 40° C, when the degree of dilution 
is noted at which the bit of egg-albumin is just dissolved. The 
greater the degree of dilution at which digestion still takes place, the 
greater the amount of pepsin or of its zymogen present. 

If it is desired to definitely exclude the presence of pepsin and 
pepsinogen in the stomach, the method of Jaworski should be em- 
ployed. To this end about 200 c.c. of a decinormal solution of hy- 
drochloric acid are poured into the stomach through a tube and as- 
pirated after one-half hour. If the fluid removed contains no 
pepsin, the absence of both the enzyme and its zymogen may be in-r 
ferred. 

The Milk-curdling Ferment and its Zymogen, viz, Chymosin 
and Chymosinogen. — A great deal of what has been said above 
regarding pepsin and its zymogen also holds good for chymosin and 
its proenzyme. The proenzyme thus also appears to be formed by 
the cell, as a neutral aqueous extract of the mucous membrane of the 
stomach does not, as a rule, contain the ferment, but the zymogen, 
the ferment only resulting when the latter is treated with a free acid. 
It differs from pepsin in that it can exert its physiologic activity in 
feebly acid, neutral, and even feebly alkaline solutions. Exposure 



CHEMICAL EXAMINATION OF THE GASTRIC JUICE. 161 

of an active solution of chymosin, containing 3 p. m. of free hydro- 
chloric acid, moreover, to a temperature of from 37° to 40° C, 
leads to its destruction, while pepsin is not affected under the same 
conditions. 

Its specific action is exerted upon milk, or lime-containing solu- 
tions of casein, which are coagulated in neutral or feebly alkaline so- 
lutions. 

In this connection it is important to note that the addition of a few 
c.c. of a solution of calcium chloride, or any other soluble lime salt, 
results in a transformation of the zymogen into the physiologically 
active ferment, and that hydrochloric acid, while it normally causes 
such transformation, is not absolutely necessary in the presence of 
calcium chloride. 

Under physiologic conditions chymosin and its zymogen are 
always present in the gastric juice. In disease the inferences that 
may be drawn from a quantitative estimation of the ferment and its 
zymogen have been well formulated by Boas, to whom we are espe- 
cially indebted for a great deal of valuable information in this con- 
nection : 

1. Notwithstanding the absence of free hydrochloric acid, chymosin 
may be present, although in minimal traces, i. <?., demonstrable with 
a dilution of from 1 : 10 to 1 : 20 (see method on p. 162). 

2. In the absence of free hydrochloric acid the zymogen may still 
be present in normal amounts, i. e., demonstrable with a dilution of 
from 1 : 100 to 1 : 150. The presence of the zymogen, especially 
when repeatedly observed, permits of the conclusion with a high 
degree of probability, and even with absolute certainty, that we are 
not dealing with an organic disease of the stomach, but with a 
neurosis, or a hypersemic condition of the mucous membrane, refer- 
able to disease of other organs. 

3. The zymogen may occur in moderately diminished amount, 50 
per cent, only being present. This is usually owing to the existence 
of a gastritis, which has not as yet reached its highest degree of 
severity. The nearer the amount of zymogen approaches the nor- 
mal, the greater will be the probability of an ultimate recovery under 
suitable treatment. 

4. The amount of the zymogen is greatly diminished (dilutions of 
1 : 10 to 1 : 25 yielding a negative result), or may be absent alto- 
gether. In cases of this kind a severe and usually incurable gas- 
tritis exists, either primary or occurring secondarily to carcinoma, 
amyloid degeneration, etc. 

5. In 1, 2, and 3 the reestablishment of the secretion of hydro- 
chloric acid may be attempted with some prospect of success by 
means of stimulating remedies. 

These conclusions are based upon the employment of Ewald's test- 
11 



162 THE GASTRIC JUICE AND GASTRIC CONTENTS. 

breakfast, and cannot be applied to observations made after other 
test-meals, without previous studies in this direction. 

Testing for the presence of chymosin and its zymogen, moreover, 
is of decided value in cases in which alkaline material is vomited, 
and where we may be called upon to decide whether this contains 
constituents of the gastric juice or not. 

Tests for Chymosin and Chymosinogen. — Test for the enzyme: 
Five to ten c.c. of milk are treated with from three to five drops of 
the filtered gastric juice and kept at a temperature of from 37° to 
40° C. for ten to fifteen minutes. If coagulation occurs during this 
time, it may be definitely concluded that the enzyme is present. 

Test for the zymogen : 10 c.c. of filtered and feebly alkaline gastric 
juice are treated with 2 or 3 c.c. of a 1-per-cent, solution of calcium 
chloride, and kept at a temperature of from 37° to 40° C, when in 
the presence of the zymogen the formation of a thick cake of casein 
will be observed to occur within a few minutes. 

Quantitative Estimation. — Of the Exzyme : This is based upon 
the fact that upon gradually diluting a specimen of gastric juice a 
point is finally reached at which a chymosin reaction can no longer 
be obtained, the value being, of course, a relative one. Under phys- 
iologic conditions a positive reaction can still be observed with a 
degree of dilution, varying between 1 : 30 and 1 : 40. 

The gastric juice is neutralized with a very dilute solution of 
sodium hydrate. Tubes are then prepared containing from 5 to 10 
c.c. of the gastric juice, variously diluted in the proportion of 1 : 10, 
1 : 20, 1 : 30, etc., to which an equal amount of neutral or amphoteric 
milk is added. The tubes, properly labelled, are kept at a tempera- 
ture of from 37° to 40° C, when the degree of dilution is noted at 
which coagulation still occurs. 

Of the Zymogen. — The gastric juice is rendered feebly alka- 
line and tubes are prepared containing equal amounts of milk and 
gastric juice, the latter variously diluted, as above directed ; the ex- 
amination is then carried on in the same manner, formally a pos- 
itive reaction is obtained with a dilution varying between 1 : 100 and 
1 : 150. Allowance must, of course, be made for the amount of 
fluid which is added during the process of neutralization. 

The Products of Gastric Digestion. 

The Digestion of Native Albumins. — The first step in the proc- 
ess of albuminous digestion, in the stomach, is one of swelling, 
which may be observed when a flake of fibrin, for example, is placed 
in gastric juice, and the temperature maintained between 37° and 
40° C. Very soon simple dissolution takes place, which is followed 
by the process of " denaturization," as Neumeister terms it, in 



CHEMICAL EXAMINATION OF THE GASTRIC JUICE. 163 

which the native albumins are transformed into acid albumins or 
syntonins, owing to the continued activity of the hydrochloric acid 
and pepsin. The pepsin, however, only acts as an adjuvant to the 
acid, and hydrochloric acid alone is capable of effecting the same 
result. While in the absence of pepsin more concentrated solutions 
of the acid and a higher temperature are required, the temperature 
of the body and the amount of hydrochloric acid secreted by the 
stomach are sufficient when pepsin is present. Pepsin, in the ab- 
sence of free hydrochloric acid, is perfectly inert. 

The " denaturization ? , of the native albumins is followed by a 
splitting up of the albuminous molecule and a process of hydration, 
the so-called primary albumoses, of which there are two, viz, proto- 
albumose and heteroalbumose, being the first products thus formed. 

Dysalbumose, it may be stated in passing, is merely a modified 
form of heteroalbumose, which results when this is dried or kept 
under water for some time. 

During the further process of digestion a deuteroalbumose results 
from each of the primary albumoses, and from these finally peptones, 
to which, in contradistinction to the peptones formed during the 
process of pancreatic digestion, the term amphopeptone has been ap- 
plied by Kuhne. 1 

The relation existing between the various products of gastric 
digestion may be seen from the following table (taken from Neu- 
meister) : 

Native albumin. 
I 



Protoalbumose. Heteroalbumose (dysalbumose). 

Deuteroalbumose. Deuteroalbumose. 

Peptone (amphopeptone). Peptone (amphopeptone). 

The transformation of native albumins into peptones, as described, 
was first worked out for fibrin, but was subsequently shown to hold 
good for all native albumins, of both vegetable and animal origin. 
Chittenden proposes the generic term " proteoses " for these various 
products of digestion, in contradistinction to those resulting from 
albuminoids. Vitellin thus first yields two primary vitelloses, viz, 
a proto- and a heterovitellose, which are transformed into deutero- 
vitelloses and finally into peptones. The albumoses of fibrin are 

decent research seems to show that still other albumoses are formed during the 
process of digestion, and that the <r/<//-portion of the amphopeptone, at least, can no 
longer be regarded as a unity. It is apparently a mixture of several different sub- 
stances, and consists to a not inconsiderable degree o( hexon bases, viz. arginin, 
lysin, and histidin. 



164 THE GASTRIC JUICE AND GASTRIC CONTENTS. 

similarly termed fibrinoses ; those of the globulins, globulinoses ; 
and those of myosin, myosinoses. 

The digestion of casein, which belongs to the class of nucleoalbu- 
mins, differs from the process described. The casein of the milk is 
present in solution as a neutral calcium salt, and as it has the charac- 
ter of a polybasic acid, calcium chloride, and the corresponding acid 
casein salt will result in the presence of the hydrochloric acid of the 
stomach ; still later, when more hydrochloric acid has been secreted, 
insoluble casein, as such, will be found. While the acid is thus 
capable of causing the precipitation of casein, it has also been shown 
that the same result may be reached in the absence of hydrochloric 
acid. According to Hammarsten, this is brought about in conse- 
quence of the hydrolytic action on the part of the chymosin, the cal- 
cium salt of paracasein (cheese) and a small amount of an albumose-like 
posset-albumin being formed. This latter process is now supposed 
to take place in the stomach after the hydrochloric acid has previ- 
ously transformed the neutral into the acid casein salt. When this 
stage is reached the paracasein is split up into an albumin and an 
insoluble nuclein. The albumin is then further digested as described, 
two primary caseoses first resulting, which are then transformed 
into deutero-caseoses, and these finally into peptones. 

The remaining proteids, such as haemoglobin, glucosides, etc., are 
similarly acted upon by the gastric juice, being first split up into 
the corresponding albumins and their pairlings. Haemoglobin is thus 
broken down into hamiatin and an albumin, which latter undergoes 
the same process of digestion, as is seen in the case of the native 
albumins. 

The Digestion of the Albuminoids. — Of the albuminoid bodies 
only collagen and elastin undergo digestion in the stomach, gelatoses 
and elastoses being formed during the process, while keratin passes 
off undigested. Heteroproteoses, however, are formed from neither 
collagen nor elastin, but merely protoproteoses, which in turn are 
transformed into deuteroproteoses, of which there is only one kind, 
viz, that corresponding to the protoproteose, peptone finally resulting. 

The Digestion of Carbohydrates. — The secretion of the stomach 
itself is not capable of digesting carbohydrates. There appears to 
be no doubt, however, that a transformation of starches into sugar 
takes place during the earlier stages of digestion. This is owing to 
the continued action of the pytalin of the saliva (see p. 123) in the 
stomach, which goes on until the amount of hydrochloric acid se- 
creted reaches 0.01 or more per cent., it being remembered that the 
transformation of starches into sugar goes on best in a neutral or 
feebly alkaline medium. 

The question whether or not a diastatic ferment occurs in the 
mucus secreted by the stomach itself is unimportant, as cases have 



CHEMICAL EXAMINATION OF THE GASTRIC JUICE. 165 

but rarely been observed in which there was an absence of ptyalin 
from the saliva. 

As indicated in the chapter on Saliva, a large number of inter- 
mediary products are formed in the transformation of starch into 
sugar, of which an idea may be had from the accompanying table : 

Starch. 

I 
Amidulin. 

| 

I ; 1 

Erythrodextrin. Maltose. 

I I 

Achroodextrin a Maltose. 

I . I 

Achroodextrin /5 Maltose. 

I . I 

Achroodextrin y (maltodextrin). Maltose. 

I I 

Maltose. Maltose. 

In the mouth this transformation is very rapidly effected in the 
case of certain starches, such as corn-starch and rye-starch, and it is 
possible to demonstrate the presence of sugar after from two to six 
minutes. Potato-starch, on the other hand, requires a much longer 
time, viz, from two to four hours. This difference is entirely de- 
pendent upon the varying degree of resistance offered to the action 
of the saliva by the enclosing envelope of cellulose, as is apparent 
from the fact that a paste made from potatoes is just as rapidly di- 
gested as one made from rye. 

For practical purposes, the digestion of carbohydrates in the 
stomach may be disregarded as insignificant. 

Fats are not digested at all in the stomach. 

From the above considerations it is apparent that under physio- 
logic conditions a mixture of these various products is met with in 
the stomach at the height of digestion, and it might be expected that 
from a preponderance of the one over the other definite and valuable 
conclusions as to the digestive power of the organ could be reached. 
While this is true in a certain sense, the quantitative methods of 
analysis that would have to be employed in order to obtain definite 
data are as yet too complicated for the purposes of the clinician, and 
from the simple qualitative tests not much information can be de- 
rived. The recognition of the presence of peptones would thus 
merely indicate the presence of hydrochloric acid and pepsin in a 
general way, as peptones may be formed in the absence of hydro- 
chloric acid and in the presence of organic acids, which may be found 
in pathologic conditions. A portion of the albumin of milk, eggs, 
meat, etc., is, moreover, already peptonized during t he process of 
boiling. It is not surprising then that peptones may be demonstrated 
in practically every specimen of gastric contents. 



166 THE GASTRIC JUICE AND GASTRIC CONTENTS. 

A large amount of syntonin and primary albumoses in the presence 
of a feeble peptone-reaction must, of course, be regarded as abnormal, 
pointing to a defective secretion of either hydrochloric acid or the 
enzymes, or of both. The same may be said to hold good when a 
pronounced peptone-reaction disappears upon the removal of syntonin 
and the primary albumoses. 

So far as the examination for the products of carbohydrate diges- 
tion is concerned, it may be stated, as a general rule, that in the 
presence of a normal amount of hydrochloric acid erythrodextrin can 
usually be demonstrated toward the end of gastric digestion, while 
achroodextrin is almost always obtained at that time when free hydro- 
chloric acid is absent, so that the tests for the presence of these two 
bodies may be regarded as roughly indicating the presence or absence 
of free hydrochloric acid. Boas draws attention to the fact, however, 
that ptyalin may, at times, though rarely, be absent, when conclusions 
drawn from these tests as to the presence of hydrochloric acid would 
be erroneous. 

The tests for sugar in the gastric juice do not furnish any infor- 
mation that is of practical value. 

Analysis of the Products of Albuminous Digestion. 

In order to separate the various bodies referred to from each other 
the following procedure may be employed : 

The filtered gastric contents are carefully neutralized with a dilute 
solution of sodium hydrate, using litmus-paper to determine the re- 
action ; a small drop of the mixture is placed upon the paper from 
time to time during the addition of the sodium hydrate until no 
change in color is produced either on the red or the blue paper. If 
syntonin is present, it will be precipitated, and can be collected on a 
small filter. Upon the addition of an excess of dilute acid or an 
alkali this precipitate will again be dissolved. The filtrate is feebly 
acidified by the addition of a few drops of a very dilute solution of 
acetic acid, treated with an equal volume of saturated solution of 
common salt, and brought to the boiling-point. Any native albumin 
that may be present in solution is thus coagulated and can be filtered 
off on cooling. In the filtrate the albumoses and peptones remain. 
The presence of the former may be demonstrated by adding a few 
drops of nitric acid to a specimen, when a precipitate will form which 
dissolves upon the application of heat, and reappears on cooling ; 
if necessary, the specimen may be diluted. 

Should the deuteroalbumoses of vitellin or myosin be present, 
however, this test yields a negative result, and a precipitate only oc- 
curs when the solution, acidified with nitric or acetic acid, is com- 
pletely saturated with sodium chloride. 



CHEMICAL EXAMINATION OF THE GASTRIC JUICE. 



167 



The presence of primary albumoses may be established by adding 
pieces of rock-salt to the neutral solution, when a precipitate occurs. 
The albumoses may be roughly separated from the peptones by satu- 
rating the acidified filtrate just obtained with pulverized ammonium 
sulphate, whereby the albumoses are almost entirely precipitated. 
A small portion of deuteroalbumoses, however, which resulted from 
the protoalbumoses, remains in solution and passes into the filtrate, 
which also contains all of the amphopeptone. In the filtrate this 
may be demonstrated as follows : A concentrated solution of sodium 
hydrate is added until all the ammonium sulphate has been trans- 
formed into sodium sulphate, and a slight excess of the hydrate is 
present ; care should be had, however, that the temperature does not 
rise too high, by immersion in cold water. The sodium sulphate, 
which separates out during this process, is allowed to settle. A 2- 
per-cent. solution of sulphate of copper is then carefully added drop 
by drop, to a specimen of the supernatant fluid, when in the presence 
of peptones a rose to a purplish-red color will develop. 

To obtain the peptones, the filtrate is diluted with an equal volume 
of water, neutralized, and then treated with a solution of tannic acid, 
care being taken to avoid an excess, as the peptone-precipitate is 
otherwise partly dissolved. 

From the following table an idea may be formed of the reactions 
of these various bodies : 

Reaction of the Individual Peoteids. 



Soluble in 



Insoluble in 



Precipitated by 



Biuret reaction 



Globulin. 



Dilute solutions of 
sodium cbloride 
and of magne- 
sium sulphate. 

Water. 



Much water, heat- 
ing to 75°C., satu- 
ration with mag- 
nesium sulphate 
from its solutions 
in neutral salts. 



Violet, 



Syntonin. 



Dilute acids and 
alkalies. 



Water and neutral 
salt solutions. 

Neutralization of 
its solutions in 
dilute acids, by 
means of sodium 
chloride or heat- 
ing to 75° C, from 
acid solutions. 



Heniialbumose. 



Peptone. 



Water, acids, alka- | Water, acids, acids 
lies, and salts. -f- salts, alkalies. 



Acetic acid 4- sodi- 
um chloride, con- 
centrated nitric 
acid, acetic acid, 
and potassium 
ferro-cyanidc in 
the cold. 



Violet. 



Rose t. 



^ii i 



Bichloride of mer- 
cury, tannic acid, 
iodo-mevcuric io- 
dideof potassium, 
phospho-tungstic 
and phospho-mo- 
h bdic acids. 

Rose to purple. 



Tests for the Products of Carbohydrate Digestion. 

Starch may be recognized by the fact that it strikes a blue color 
with a solution of iodo-potassic iodide, while the same solution gives 
a violet or mahogany-brown with erythrodextrin. To this end it 
is only necessary to add a drop or two of Lugol's solution to a few 
c.c. of the filtered gastric juice. The presence of achroodextrin may 



168 THE GASTRIC JUICE AND GASTRIC CONTEXTS. 

be inferred if no change in color occurs upon the addition of the 
reagent. 

Maltose and dextrose, which both react with Fehling's solution 
and undergo fermentation, differ from each other by the fact that 
the former does not reduce BarfoecVs reagent. This is prepared by 
adding a 1-per-cent. solution of acetic acid to an 0.5- to 4-per-cent. 
solution of acetate of copper. Upon boiling a few c.c. of this solu- 
tion, and adding a small amount of filtered gastric contents, red 
cuprous oxide will be precipitated in the presence of maltose. 

Lactic Acid. 

Mode of Formation and Clinical Significance.— It was formerly 
thought that the acidity of the gastric juice was referable to the presence 
of lactic acid, as this can always be demonstrated in the beginning of 
the process of digestion. The hydrochloric acid was thought to re- 
sult from an action of the lactic acid upon the chlorides of the food. 
That this view was erroneous C. Schmidt succeeded in demonstrating 
beyond a doubt, as has been shown on p. 139. An explanation of the 
presence of lactic acid suggested itself when Miller found that nor- 
mally various bacteria occur in the mouth which are capable of 
forming lactic acid from sugar, and that a number of bacteria can be 
isolated from the gastric contents, which are capable of causing an 
acid fermentation in sugar-containing media. 

There would, hence, be nothing surprising in the constant occur- 
rence of lactic acid, as the two principal factors necessary for its 
formation are always present after the ingestion of an ordinary meal, 
viz, carbohydrates and bacteria capable of causing lactic-acid fer- 
mentation. The absence of the lactic acid during the later stages of 
digestion was, furthermore, explained by the fact that lactic-acid fer- 
mentation ceases in the presence of from 0.7 to 1.6 pro mille of hydro- 
chloric acid; i. e., in the presence of amounts of hydrochloric acid which 
are found in the normal gastric juice. The occurrence of lactic-acid 
fermentation in the stomach was, until quite recently, therefore, re- 
garded as an established fact. At this stage Martius and Liittke, 
employing the method already described, found "that the accurately 
determined curve of acidity referable to hydrochloric acid coincided 
in all respects, even at the beginning of the process of digestion, 
with the curve referable to the total acidity," so that lactic acid as a 
physiologic constituent could not have been present. 

Recent researches of Boas, moreover, appear to prove beyond a 
doubt that in physiologic conditions no appreciable amounts of lactic 
acid are formed during the process of digestion, and that the lactic 
acid found after an ordinary meal has been introduced into the stom- 
ach as such. That lactic acid is actually present in the various kinds 



CHEMICAL EXAMINATION OF THE GASTRIC JUICE. 169 

of bread has been definitely proven, and it is, hence, not permissible 
to make use of any test-meal containing lactic acid, when the ques- 
tion as to its formation in the stomach, is to be considered. For 
these reasons Boas suggests the use of simple oatmeal-soup to which 
salt only has been added. For practical purposes this is probably 
not always necessary, as the small amount of lactic acid found after 
Ewald's test breakfast may usually be disregarded ; an increased 
amount can be directly referred to pathologic conditions. 

The fact that the lactic acid disappears, or is at least no longer 
demonstrable, at the height of digestion, Boas refers to a resorption 
or a carrying off of the acid introduced, on the one hand, or to an 
interference of the hydrochloric acid with the delicacy of the reagent 
usually employed — i. e., Uffelmann's reagent — on the other. Path- 
ologically the same rule may be said to hold good, as Boas was un- 
able to demonstrate its presence after the exhibition of his test-meal 
in the most divers diseases of the stomach, viz, chronic gastritis, 
atony and dilatation, referable to myasthenia, or pyloric stenosis, 
following ulcer, etc. Mere traces, which were occasionally observed, 
are of no significance, and possibly referable to lactic-acid fermenta- 
tion having taken place in the mouth. In all the cases examined, 
moreover, no organic acids could be demonstrated by the method of 
Hehner-Seemann (see p. 177). 

It is apparent then that notwithstanding stagnation of the gastric 
contents and the absence of free hydrochloric acid in normal amounts, 
lactic acid is not necessarily formed in the stomach, even in the 
presence of carbohydrates. In only one disease of the stomach was 
lactic acid found in notable quantities, viz, in carcinoma. This ob- 
servation is in accord with the fact that Uffelmann's test here yields 
a marked reaction — i. e., a deep lemon, or a canary-yellow color — 
even upon the addition of but few drops of the gastric juice, while 
in the benign affections only a pale-yellow, brownish, or grayish 
color is obtained. 

Boas' test-meal should be given the evening before the examina- 
tion, the stomach having been previously washed free from all 
remnants of food ; the remaining contents are obtained the next 
morning. 

In an analysis of fourteen cases of carcinoma Boas was able to 
demonstrate the presence of lactic acid in amounts varying between 
1.22 and 3.82 p. m. in all cases but one, while in other diseases after 
the ingestion of Ewald's test-breakfast only from 0.1 to 0.3 p. m. 
could be obtained. 

Unfortunately recent investigations have shown that notable 
amounts of lactic acid may also be found in gastric anadenv, and in 
cases of dilatation referable to benign causes. Such eases, however. 
are rare, and it may be safely stated that the presence of large 



170 THE GASTRIC JUICE AND GASTRIC CONTENTS. 

amounts of lactic acid will almost invariably justify the diagnosis of 
carcinoma of the stomach. 

That stagnation of the gastric contents and the absence of free 
hydrochloric acid alone are not capable of causing the formation of 
lactic acid has been seen, and it is, hence, difficult to explain why in 
carcinoma, practically only, lactic-acid fermentation should occur. 
Whether the malignant growth itself must be regarded as one of the 
principal factors in this connection, as Boas suggests, must still re- 
main an open question. 

Owing to the interest which attaches to this subject, it may not 
be out of place to briefly refer to the following observation of Koch : 
In a case, in which ulcer of the stomach existed, the hydrochloric 
acid suddenly disappeared and gave place to lactic acid, which then 
steadily increased in amount from week to week. A tumor could 
not be demonstrated on physical examination. Soon after, the patient 
died, and at the autopsy a carcinoma of the stomach was found upon 
the base of the pyloric ulcer. An exploratory operation should hence 
be made, whenever notable amounts of lactic acid can be repeatedly de- 
monstrated in the stomach contents, after the ingestion of Boas' test-meal. 
Negative results, however, do not exclude the existence of carcinoma. 

The formation of lactic acid from starch may be represented by 
the following equations : 

I. 2C 6 H 10 O 5 +H 2 0= C 12 H 29 O n (milk sugar). 
II. C 12 H 22 O n 4- H 2 = 2C 6 H r ,0 6 (glucose). 
III. 2C 6 H 12 6 =4C 3 H 6 "0 3 (lactic acid). 

It should, finally, be mentioned that only that form of lactic acid 
which results from fermentative processes is of interest in this con- 
nection, and not the sarcolactic acid contained in meat — a point 
which interferes with the general usefulness of KiegePs test-meal. 

Tests for Lactic Acid. — For the reasons indicated Boas' test- 
meal (see p. 134) should be employed whenever it is desired to test 
for lactic acid in the gastric contents. If the case under examina- 
tion shows well-marked symptoms of stagnation of the gastric con- 
tents, the stomach should be washed out completely in the evening, 
the soup given then, and the gastric contents procured the next 
morning, before any food or liquid is taken. Otherwise the test- 
meal may be given in the morning on an empty stomach, without 
previous lavage, and the contents examined one hour later. 

Uffelmann's Test. — Heretofore Uffelmann's reagent was quite con- 
stantly employed in testing for lactic acid, but everyone who has 
had occasion to make frequent use of this reagent in clinical work, 
must have been struck with the uncertainty of the results so often 
obtained. In a large majority of the cases thus examined, particu- 
larly, if EwakPs test-breakfast is employed, a characteristic reaction 



CHEMICAL EXAMINATION OF THE GASTRIC JUICE. 171 

— i. e., the occurrence of a lemon or canary yellow color — is not 
seen, notwithstanding the presence of lactic acid, but a pale-yellow, 
brownish, grayish-white, or even gray color is obtained instead, often 
leaving in doubt whether lactic acid is present or not. Aside from 
doubtful results, the value of the test is greatly diminished by the 
fact that glucose, acid phosphates, butyric acid, and alcohol give the 
same reaction, and that in the presence of such amounts of hydro- 
chloric acid as are found at the height of normal digestion, lactic 
acid is not indicated by the reagent. All these difficulties have long 
been appreciated, and in order to obviate at least some of them it 
was proposed to apply the test to an aqueous solution of the ethereal 
extract of the gastric contents : 

To this end 5 or 10 c.c. of the nitrated gastric juice are extracted, 
by shaking, with from 50 to 100 c.c. of neutral sulphuric ether in a 
stoppered separating funnel for about twenty or thirty minutes ; the 
ethereal extract is then evaporated on a water bath, or the ether 
distilled off (no flame). The residue is taken up with from 5 to 
10 c.c. of distilled water, and tested as follows : Three drops of a 
saturated aqueous solution of the sesquichloride of iron are mixed 
with three drops of a concentrated solution of pure carbolic acid 
and diluted with water until an amethyst-blue color is obtained. 
To this solution a portion of the ethereal extract is added, when in 
the presence of only 0.1 per cent, of lactic acid a lemon or canary- 
yellow color is obtained. 

Kelling's Method. — Five or ten c.c. of gastric juice are diluted 
from ten to twenty times with water and treated with one or two 
drops of a 5-per-cent. aqueous solution of the sesquichloride of iron. 
In the presence of lactic acid a distinct greenish-yellow color is ob- 
tained, if the tube is held to the light. This test is more reliable 
than that of Uffelmann, as a positive reaction is only obtained in 
the presence of lactic acid. 

Strauss' Method. — Instead of evaporating the ether as in the 
above method, the ethereal extract may be directly examined by 
shaking with a freshly prepared solution of the sesquichloride of 
iron, as suggested by Fleischer. Making use of this principle 
Strauss has recently constructed an apparatus (Fig. 34) which may 
be found very convenient and which permits of roughly determin- 
ing the amount of lactic acid present. The instrument is essentially 
a separating-funnel of 30 c.c. capacity, bearing two marks, of which 
the one corresponds to 5 c.c, the other to 25 c.c. The apparatus is 
filled with gastric juice to the mark 5, when ether is added to the 
25 c.c. line. After shaking thoroughly the separated liquids arc 
allowed to escape by opening the stopcock until the 5 c.c. mark is 
reached. Distilled water is then added to the 25 mark, and the 
mixture treated with two drops of the officinal tincture of the 



172 THE GASTRIC JUICE AND GASTRIC CONTENTS. 

sesquichloride of iron, diluted in the proportion of 1:10. Upon 
shaking the water will assume an intensely green color, if more than 
1 p. m. of lactic acid is present, while a pale green is obtained in the 
presence of from 0.5 to 1 p. m. The tincture of iron should be kept 
in a dark-colored dropping-bottle of about 50 c.c. capacity. 

It will be observed that only large amounts of lactic acid, which 
are alone of importance from a diagnostic point of view, are indicated 
by the apparatus. Small amounts, as those introduced with Ewald's 

Fig. 34. 




Strauss' apparatus for the approximative estimation of lactic acid. 

test-breakfast, or referable to lactic-acid fermentation in the mouth, 
are not indicated, so that confusion as to the presence or absence of 
the acid can never arise. 

Boas' Method. — In doubtful cases the following method should be 
employed, as with it, and following the exhibition of Boas' test-meal, 
all possible errors can be avoided. The stomach must, however, be 
washed perfectly clean, before the test-meal is introduced. It is my be- 
lief that some of the positive results which have been obtained in 
other diseases than carcinoma, are referable to neglect in this partic- 
ular point. Aldehyde is not infrequently found in the stomach 
contents, when sarcinse are present in large numbers, and may be 
mistaken for lactic acid, as I discovered to my regret not long ago. 

Principle of the method : When a solution of lactic acid is treated 
with a strong oxidizing agent and heated, the lactic acid is decom- 
posed into acetic aldehyde and formic acid, according to the equa- 
tion : 

Lactic acid. Acetic aldehyde. Formic acid. 

CH 3 — CH ( OH ) — CO. OH = CH 3 . CHO + H. CO. OH. 

Practically, then, the test for lactic acid resolves itself into a test for 
acetic aldehyde, which can be readily recognized by testing with 
various reagents, such as an alkaline solution of iodo-potassic iodide, 
Nessler's reagent and others. INessler's reagent is prepared as fol- 
lows : Two grammes of potassium iodide are dissolved in 50 c.c. of 
water and treated with iodide of mercury, while heating, until some 
of the latter remains undissolved. Upon cooling, the solution is 
diluted with 20 c.c. of water. Two parts of this solution are then 



CHEMICAL EXAMINATION OF THE GASTRIC JUICE. 173 

treated with 3 parts of a concentrated solution of potassium hydrate ; 
any precipitate that may have formed is filtered off and the reagent 
kept in a well-stoppered bottle. When aldehyde is added to such a 
solution a yellowish-red or red precipitate results, the exact color 
depending upon the amount of aldehyde present. One part of the 
aldehyde may still be recognized, when diluted with 40,000 parts of 
water. 

With an alkaline solution of iodo-potassic iodide, aldehyde, in a 
dilution of 1 : 20,000, will still produce a cloudiness, referable to the 
formation of iodoform, which is readily recognized by its character- 
istic odor (Lieben's test for acetone). 

Method : The filtered gastric juice is tested for the presence of 
free acids with Congo-red (see p. 147). If present, from 10 to 20 
c.c. are evaporated to a syrup on a water-bath, after the addition of 
an excess of barium carbonate, while the latter is unnecessary in the 
absence of free acids. The syrup is treated with a few drops of 
phosphoric acid, and the carbon dioxide removed by bringing it to 
the boiling point, once only, when it is allowed to cool and extracted 
with 100 c.c. of neutral sulphuric ether (free from alcohol), by shaking 
for half an hour. The layer of ether is poured off after half an hour, 
the ether is evaporated (no flame), the residue taken up with 45 c.c. of 
water, shaken and filtered, and finally treated with 5 c.c. of sulphuric 
acid and a pinch of dioxide of manganese in an Erlenmeyer flask. 
This is closed with a perforated stopper carrying a glass tube bent 
to an obtuse angle, the longer limb of which passes into a narrow 
glass cylinder containing from 5 to 10 c.c. of Nessler's reagent or a 
like quantity of an alkaline solution of iodo-potassic iodide. If heat 
is now carefully applied, the aldehyde, formed by the oxidation of 
the lactic acid with manganese dioxide and sulphuric acid, passes 
over, when the boiling-point is reached, and causes the precipitation of 
yellowish-red aldehyde of mercury in the tube containing the Nessler's 
reagent, or of iodoform, if the alkaline solution of iodine is employed. 

Quantitative Estimation of Lactic Acid According" to Boas' 
Method. — The principle already set forth also applies to the quanti- 
tative estimation of lactic acid. 

Solutions required : 

1. A one-tenth normal solution of iodine. 

2. A one-tenth normal solution of sodium thiosulphate. 

3. Hydrochloric acid (sp. gr. 1.018). 

4. A potassium hydrate solution (56 : 1,000). 

5. Starch solution. 
Preparation of these solutions : 

1. A normal solution of iodine should contain 126.53 (mol. weight 
of iodine) grammes of iodine in the litre, and a one-tenth normal 
solution, hence, 12.6 grammes. In order to dissolve the iodine 25 



174 THE GASTRIC JUICE AND GASTRIC CONTENTS. 

grammes of potassium iodide are dissolved in about 200 c.c. of dis- 
tilled water, when the 12.6 grammes of resublimed iodine are added. 
This solution is then diluted with distilled water to the 1,000 c.c. 
mark, and requires no further correction. 

2. The one- tenth normal solution of sodium thiosulphate is pre- 
pared as described in the chapter on Acetone (see Urine). When 
treated with one gramme of ammonium carbonate pro litre, it will 
retain its titre almost indefinitely. 

3. Preparation of the starch solution : 5 grms. of starch are dis- 
solved in 900 c.c. of water by heatiug, when 10 grms. of zinc 
chloride in 100 c.c. of water are added. 

Method. — Ten to twenty c.c. of the filtered gastric juice are first 
treated, as indicated above, viz, evaporated to a syrup after the pre- 
vious addition of barium carbonate, if free acids are present. A 
few drops of phosphoric acid are added, the carbon dioxide re- 
moved by boiling, and the residue extracted, on cooling, with 100 
c.c. of ether free from alcohol; the ether is evaporated after separa- 
tion, the residue taken up with 45 c.c. of distilled water, and treated 
with manganese dioxide and sulphuric acid. The flask is closed by 
a doubly perforated stopper ; through one aperture a bent tube passes 
to the distilling-apparatus, and a straight tube provided with a 
piece of rubber tubing, clamped off, through the other. The mix- 
ture is distilled until about four-fifths of the contents have passed 
over, excessive heat being carefully avoided, as otherwise the aldehyde 
will be decomposed, according to the equations : 

Lactic acid. Aldehyde. Formic acid. 

I. CH 3 — CH(OH) — CO. OH = CH 3 .CHO + HCOOH. 

Aldehyde. Formic acid. Acetic acid. 

II. CH3.CHO + HCOOH + 20 = CH 3 .COOH + C0 2 + H 2 0. 

To the distillate, which is best received in a high Erlenmeyer 
flask, well stoppered, 20 c.c. of the one-tenth normal solution of 
iodine are added, mixed with 20 c.c. of the 5.6-per-cent. solution of 
potassium hydrate. The mixture is shaken thoroughly and allowed 
to stand for a few minutes. In order to liberate the iodine not used 
in the reaction, 20 c.c. of hydrochloric acid are added, and the ex- 
cess of iodine determined by titration with the one-tenth normal solu- 
tion of sodium thiosulphate. The titration is carried almost to the 
point of decolorization, when a little starch solution is added ; the 
mixture is then titrated until the blue color has disappeared. The 
number of c.c. of the one-tenth normal solution employed, viz, 
20, minus the number of c.c. of the one-tenth normal solution of 
sodium thiosulphate, will then indicate the number of c.c. of the 
former required for the formation of iodoform, viz, the amount of 



CHEMICAL EXAMINATION OF THE GASTRIC JUICE. 175 

lactic acid present in 10 or 20 c.c. of gastric juice, as the case may 
be. As 1 c.c. of the one-tenth normal solution of iodine has been 
found to indicate the presence of 0.003388 gramme of lactic acid, it 
is only necessary to multiply the number of c.c. used by this figure, 
and the result by 10, in order to obtain the percentage. 

The method described is reliable and sufficiently accurate for clin- 
ical purposes. At the same time it may be said that no more time 
is required than in the ordinary quantitative estimation of sugar by 
means of Fehling's method, or of hydrochloric acid, according to the 
method of Martius and Ltittke. 

Boas' Rapid Method : This method is less accurate than the 
one preceding, but may be advantageously employed in the absence 
of the various reagents necessary with the former. Ten c.c. of fil- 
tered gastric juice are treated with a few drops of dilute sulphuric 
acid, and the albumin present removed by heat. The filtrate is evap- 
orated to a syrup on a water bath, water added to the original 
amount, and this again evaporated to a small volume, fatty acids being 
thereby removed. The lactic acid remaining is now extracted with 
ether (200 c.c. for every 10 c.c. of gastric juice) ; the ether is evap- 
orated, the residue taken up with water, and titrated with a one- 
tenth normal solution of sodium hydrate, using phenolphthalein as 
an indicator. As 40 parts by weight of sodium hydrate (mol. 
weight) combine with 90 parts by weight of lactic acid (mol. weight) 
and as 1 c.c. of the one-tenth normal solution of sodium hydrate con- 
tains 0.004 gramme of sodium hydrate, the corresponding amount of 
lactic acid is found from the equation : 40 : 90 : : 0.004 : x ; 40x = 
0.360 ; x = 0.009. The value of 1 c.c. of the one-tenth normal so- 
lution in terms of lactic acid is thus 0.009. By multiplying the 
number of c.c. used by this figure, the amount of lactic acid present 
in 10 c.c. of gastric juice is ascertained. The result multiplied by 
10 indicates the percentage. 

The Fatty Acids. 

Mode of Formation and Clinical Significance. — Unless much 
milk or carbohydrates have been ingested, fatty acids do not occur 
in the gastric contents under physiologic conditions, and it would 
appear from the researches of Boas that their formation is intimately 
associated with that of lactic acid. After the exhibition of his test- 
meal (see p. 134) he was unable to demonstrate their presence either in 
health or in the various diseases of the stomach, such as chronic gastri- 
tis, atony, or dilatation referable to benign causes, etc. In carcinoma, 
however, fatty acids, just as lactic acid, were quite constantly found. 

That butyric acid can be derived from lactic acid has been demon- 
strated by Fliigge, the reaction taking place according to the equation : 

2C 3 H 6 3 = C 4 H 8 O a + 2CO,-f4H. 



176 THE GASTRIC JUICE AND GASTRIC CONTENTS. 

This observation is probably explained by the fact that most of the 
organisms causing butyric-acid fermentation are anaerobic, while the 
bacillus acidi lactici and the o'idium lactis eagerly absorb oxygen. 

Acetic-acid fermentation, on the other hand, presupposes the pres- 
ence of alcohol, whether this is introduced into the stomach as such 
or whether it results from the action of yeast (saccharomyces cere- 
visile) upon sugar. The transformation of alcohol into acetic acid is 
represented by the equation : 

C 2 H 5 OH + 20 = C 2 H 4 2 + H 2 0, 

while the formation of alcohol during the process of fermentation 
from glucose is shown below : 

I. C 6 H 12 6 + 2H 2 = 2G>H 6 + 2H 2 C0 3 . 
II. 2H 2 C0 3 = 2H 2 + 2C0 2 . 

It is, hence, necessary, whenever acetic acid is met with in the 
gastric contents, to exclude the presence of alcohol, as it is only 
then permissible to refer its presence to stagnation and advanced de- 
composition of carbohydrates. 

If the examination is confined to an analysis of the gastric con- 
tents, obtained otherwise than after the exhibition of Boas' or 
Ewald's test-meal, the diagnosis of pyloric stenosis with dilatation 
is probably always justifiable in the presence of notable quantities 
of butyric acid and acetic acid, while the same observations after a 
previous washing out of the stomach and the exhibition of Boas' 
test-meal would more strongly suggest carcinoma as the cause of the 
stenosis. 

That butyric acid may occur in the gastric contents, when butter 
or fats in general have been ingested is, of course, not surprising, 
and its presence then should be looked upon as a physiologic occur- 
rence. At the same time it should not be forgotten that butyric 
acid, just as lactic acid, may possibly have been formed in the mouth, 
and conclusions should, hence, only be drawn when such sources of 
error can be definitely excluded, and the amount found exceeds mere 
traces. 

In conclusion, it may be said that in disease butyric acid is far 
more frequently encountered in the gastric contents than acetic acid, 
but the significance of the two, if alcoholism can be excluded, is the 
same. 

Tests for Butyric Acid. — 1. Butyric acid can usually be recog- 
nized by its odor alone, which is that of rancid butter. Often, how- 
ever, it will be necessary to resort to more definite tests, such as the 
following : 

2. Ten c.c. of filtered gastric juice are extracted with 50 c.c. of 



CHEMICAL EXAMINATION OF THE GASTRIC JUICE. 177 

ether. The ether is evaporated and the residue taken up with a few 
c.c. of water. If a trace of calcium chloride in substance is now 
added, the butyric acid will separate out in the form of small oil- 
droplets, the nature of which is readily recognized by the pungent 
odor. If, instead of adding calcium chloride, a slight excess of 
baryta-water is used, strongly refractive rhombic plates or granular, 
wart-like masses of barium butyrate are obtained, upon evaporation. 

Tests for Acetic Acid. — 1. Like butyric acid, acetic acid can 
usually be recognized by its odor. 

2. Ten c.c. of filtered gastric juice are extracted with ether. The 
ether is evaporated, the residue dissolved in a few drops of water, 
and accurately neutralized with a dilute solution of sodium hydrate, 
sodium acetate being formed. If to this a drop or two of a very 
dilute solution of the perchloride of iron is added, a dark-red color 
results, in the presence of acetic acid. With nitrate of silver a pre- 
cipitate is obtained which is soluble in hot water. 

Quantitative Estimation of the Fatty Acids. — Method of Cahn- 
Mehring, modified by McNaught : The total acidity is determined in 
10 c.c. of filtered gastric juice. Another 10 c.c. are evaporated to a 
syrup, diluted with water and similarly titrated. The difference be- 
tween the two results will indicate the amount of fatty acids present. 

Quantitative Estimation of the Organic Acids. — Method of 
Hehner-Seemann : This method is based upon the observation that if 
a certain amount of a one-tenth normal solution of sodium hydrate is 
added to organic acids and the mixture is evaporated and incinerated, 
the organic acids escape as carbon dioxide, leaving their alkali be- 
hind in the form of a carbonate ; this is then determined by titration 
with a one-tenth normal solution of hydrochloric acid. The amount 
of physiologically active hydrochloric acid can be estimated at the 
same time by deducting from the total acidity the acidity referable to 
organic acids. 

Method : 10 or 20 c.c. of filtered gastric juice are titrated with 
a one-tenth normal solution of sodium hydrate, evaporated to dry- 
ness, and incinerated, the application of heat being discontinued as 
soon as the ash has ceased to burn with a luminous flame. The 
residue is taken up with water and titrated with a one-tenth normal 
solution of hydrochloric acid. This is prepared by diluting 146 
grammes of the concentrated acid (sp. gr. 1.14) with distilled water 
to about 900 c.c, when the solution is brought to the proper strength 
by comparing it witli a one-tenth normal solution o\^ sodium hydrate, 
according to directions given elsewhere. The number of c.c. ot' the 
one-tenth normal solution of hydrochloric acid employed, multiplied 
by 0.00365 will indicate the amount of fatty acids in the 10 c.c. oi' 
gastric juice, in terms of hydrochloric acid ; the 1 percentage is ascer- 
tained by multiplying by 10 or 5, as the ease may be. By deducting 
12 



178 THE GASTRIC JUICE AND GASTRIC CONTENTS. 

the number of c.c. employed from that of the one-tenth normal solu- 
tion of sodium hydrate, first used, the number of c.c. of the latter re- 
quired for the neutralization of the physiologically active hydrochloric 
acid is ascertained, and the amount determined by multiplying with 
0.00365. 

Gases. 

The stomach always contains a certain quantity of gases which 
have partly been swallowed and partly have passed into the stomach 
from the duodenum. As fermentative processes in health only occur 
when carbohydrates or fats have been ingested, and then only to a 
slight degree, nitrogen, oxygen, and carbon dioxide are the only gases 
found during the process of albuminous digestion. As the oxygen 
swallowed, is, moreover, largely absorbed by the blood, and two 
volumes of carbon dioxide are returned for one volume of oxygen, 
the presence of large amounts of the former and small amounts of 
the latter is readily explained. In an analysis of the gases contained 
in the stomach of a dog which had been fed on meat Planer found 
the following proportions : 

Carbon dioxide ...... 25.2vol. percent. 

Oxygen 6.1 " " 

Nitrogen 68.7 " " 

With a strict vegetable diet, on the other hand, hydrogen may 
also be found (Planer) : 







an. 


Dog. 


Carbon dioxide 


. 20.79 


33.83 


32.9 vol. per cent. 


Oxygen 




0.37 


0.8 " 


Nitrogen 


. 72.50 


38.22 


66.3 " 


Hydrogen . 


. 6.71 


27.58 





The presence of hydrogen is readily understood, if it is remembered 
that during the process of butyric-acid fermentation hydrogen and 
carbon dioxide are formed. Lactic-acid or acetic-acid fermentation 
does not give rise to the formation of gases. 

Marsh gas, CH 4 , a product of the fermentation of cellulose, may 
also be found in pathologic conditions, and is formed according to 
the equation : 

(C 6 H 10 O 5 )n + (H 2 O)n = 3(CO 2 )n + 3(CH i )n. 

It is yet an open question whether marsh gas is formed in the stom- 
ach or passes into the stomach from the small intestine. 

Such observations must, however, be regarded as rarities. In 
one case of this kind, examined by Ewald and Ruppstein, in which 
alcohol, acetic acid, lactic acid, and butyric acid were found in the 
vomited material, an analysis of the gases gave the following result : 



CHEMICAL EXAMINATION OF THE GASTRIC JUICE. 179 

Carbon dioxide . . . . . .20.6 vol. per cent. 

Oxygen . . . . . . . 6.5 " 

Nitrogen 41.4 " " 

Hydrogen 20.6 " 

Marsh gas 10.8 " " 

Traces of olefiant gas and of sulphuretted hydrogen were also 
found. It is curious to note that in this case the patient, who, ac- 
cording to his own statement, had " acetic acid works in his stomach 
on one day and gas works on another day,' 7 was occasionally able to 
light the eructated gas at the end of a cigar-holder, where it burnt 
with a faintly luminous flame. MclNaught has reported a similar 
case, in Avhich the analysis furnished the following results : Carbon 
dioxide = 56 per cent.; hydrogen = 28 per cent.; marsh gas = 6.8 
per cent.; atmospheric air =9.2 per cent. 

Ammonia and sulphuretted hydrogen are also at times met with ; 
their presence is always due to albuminous putrefaction. 

Boas found that sulphuretted hydrogen is quite commonly present 
in cases of dilatation referable to benign causes, while it is almost 
always absent in carcinoma. He adds that it is never found when 
lactic acid is present. In acute gastritis it may be temporarily ob- 
served. In a number of cases of carcinoma I have never found sul- 
phuretted hydrogen. In one case reported by Strauss the bacillus 
coli communis was apparently concerned in its production. 

To obtain a knowledge of the gases formed in the stomach during 
the process of digestion it is only necessary to fill an ordinary Dore- 
mus' ureometer, or an Einhorn's saccharimeter, with the unfiltered 
gastric contents, and to keep it at a temperature of from 37° to 
47° C, when the evolution of gas can be closely followed and the 
necessary tests made. The presence of carbon dioxide is readily 
recognized by passing a small amount of sodium hydrate, in concen- 
trated solution or in substance, into the tube, after the evolution has 
entirely ceased, when the fluid will rise. If other gases are present 
at the same time, they will remain after the carbon dioxide has been 
absorbed. Sulphuretted hydrogen is readily recognized by its odor 
and by the fact that it will color a piece of filter-paper, moistened 
with a few drops of sodium hydrate and acetate of lead, a more or 
less pronounced brown or black. The test is conveniently made 1 by 
filling a test-tube about half-full with the gastric contents and clos- 
ing it with a cork-stopper to which a strip of lead-paper, prepared 
as indicated, is fastened. 

The eructation of gas formed in the stomach should not be eon- 
founded with the so-called eructatio nervosa, in which no gas is either 
eructated, or air simply enters the oesophagus and is expelled again 
with a loud, explosive noise. This may be frequently observed in 
neurasthenic and hysterical individuals, and is to a greater or less 



180 THE GASTRIC JUICE AND GASTRIC CONTENTS. 

degree under the control of the will. It is hardly likely, however, 
that the physician will be called upon in the laboratory to differen- 
tiate between this form and that of true ructus, caused by fermenta- 
tive processes taking place in the stomach. The gases brought up 
in the former conditions are without odor or taste, and thus differ 
from those found in true dyspepsia. 

Acetone. 

The presence of acetone in the gastric contents in pathologic con- 
ditions has been repeatedly observed, especially by v. Jaksch and 
Lorenz, and it is curious to note that the latter was at times able to 
demonstrate larger quantities of the substance in the gastric con- 
tents than in the urine. 

In the chapter on Acetonuria the relation existing between diges- 
tive diseases and the elimination of acetone will be dealt with more 
fully, but it may here be mentioned that in the primary diseases of 
the gastro-intestinal tract acetone is quite constantly met with in 
the gastric contents, while it is but rarely observed in the secondary 
forms, and never seen in the gastric neuroses. 

This statement, however, is denied by Sovelieff, who claims to have 
found traces of acetone only in one case of nervous dyspepsia, while 
negative results Ave re obtained in all other diseases of the stomach. 
I have repeatedly been able to demonstrate the presence of acetone 
in cases of carcinoma, and have never found it in neurotic condi- 
tions. 

In order to test for acetone the gastric contents are distilled after 
the previous addition of a small amount of phosphoric acid (1 : 1,000), 
so as to prevent an excessive evolution of gases, when the tests of 
Reynolds and Gunning (see Urine) are applied to the distillate. If 
both reactions furnish a positive result, the presence of acetone may 
be regarded as demonstrated. Denniges' test may also be employed 
and can be applied to the filtered contents directly (see Urine). 

Ptomams and Toxalbumins. 

Remembering that ptomains and toxalbumins have been directly 
obtained from tainted meat, sausage, fish, clams, crabs, cheese, etc., 
it is probable and, indeed, to be expected that these bodies should 
be present in the gastric contents also. At the same time it may be 
mentioned that the stomach appears to possess the power of elimi- 
nating from the system poisons of this nature which are circulating 
in the blood. This is shown by the observations of Alt, who found 
that the water with which the stomach of an animal had been irri- 
gated, after the subcutaneous injection of the poison of Pelias berus 
and Echidna arictans, or the direct bite of the snake, produced the 



CHEMICAL EXAMINATION OF THE GASTRIC JUICE. 



181 



same symptoms of poisoning when injected into another animal. It 
is interesting to note that with lavage of the stomach the poisoned 
animal recovered. Similar observations have been made in cholera 
Asiatica. Certain vegetable alkaloids, such as morphin, are also 
known to be eliminated to a large extent by the stomach. Of the 
nature of the ptomains and toxalbumins, which may occur in the 
stomach, but very little is known. 

Vomited Material. 

Food-material. — The vomiting of large amounts of totally undi- 
gested meat two or three hours after its ingestion is a rare occur- 
rence, and is only met with in conditions associated with an entire 



Fig. 35. 




Collective view of vomited matter. (Eye-piece III., objective 8 A. Eeichert) a, muscle-fibres; 
b, white blood-corpuscles ; c, c' , squamous epithelium ; c", columnar epithelium ; d, starch-grains, 
mostly changed by the action of the digestive juices; e, fat-globules; /, sareinse ventriculi ; g, 
yeast-fungi ; h, forms resembling the comma-bacillus found by the author once in the vomit of in- 
testinal obstruction ; i, various micro-organisms, such as bacilli and micrococci ; ft, fat-needles, be- 
tween them connective-tissue derived from the food; I, vegetable cells, (v. Jakscii. ) 



absence of digestive juices from the stomach — i. e. y in cases of atro- 
phic cirrhosis of the stomach (anadeny of Ewald). This condition is 
not to be confounded with the regurgitation of undigested food, 
mixed with mucus and saliva, which is seen in cases of stricture of 
the oesophagus or of the cardiac orifice of the stomach. While at the 
outset of the latter disease the regurgitation of food occurs immedi- 
ately, or at least very soon after a meal, it may take place between 
meals in the later stages of the disease when dilatation has occurred. 
The recognition of the origin of the material brought up may then 
be exceedingly difficult. In such eases an examination should be 



182 THE GASTRIC JUICE AND GASTRIC CONTENTS. 

made for biliary coloring-matter, which, if present, will, of course, 
immediately exclude the oesophagus as the source of the material 
ejected. Unfortunately, however, the reverse does not hold good. 
Small amounts of undigested meat are of no significance. 

The vomiting of well-digested food is observed in some of the 
neuroses of the stomach, and also in certain cases of acute and sub- 
acute gastritis, ulcer of the stomach, and chronic gastritis in its early 
stages. The vomiting referable to cerebral and spinal diseases also 
belongs to this category. 

In this connection it is very important to inquire into the exist- 
ence of nausea previous to the vomiting, for, as is well known, con- 
siderable amounts of saliva and mucus may be swallowed if much 
nausea has existed, the result being that the process of digestion is 
arrested before the occurrence of vomiting. In such an event it 
would be entirely erroneous to conclude that, because the material 
ingested has not reached that stage of digestion which should be ex- 
pected at the time of the vomiting, the stomach is incapable of 
properly performing its functions. 

Mucus. — The constant presence of large amounts of mucus in 
the gastric contents, obtained with the stomach-tube, is almost path- 
ognomonic of the mucous form of gastritis, while its presence in 
vomited matter may be referable to preexisting nausea. In cases of 
pharyngitis moderate amounts of mucus are frequently found. The 
vomiting of pure mucus, according to Boas, is always pathognomonic 
of the absence of dilatation of the stomach, a statement founded on 
reason, as it is altogether unlikely that no particles of food should 
be brought up at the same time. 

Under the term gastrosuccorrhoea mucosa Dauber has recently 
described a condition in which large amounts of mucus are secreted 
by the non-digesting organ, in the absence of any symptoms pointing 
to a gastritis. I have observed a similar case occurring in a neuras- 
thenic patient, in which enormous quantities of mucus could at 
times be obtained from the fasting organ, but never during the 
process of digestion. A mild degree of hyperchlorhydria existed 
at the same time, as well as enteritis mucosa and rhinitis mucosa. 
The motor power was practically normal. 

Mucus is readily recognized on simple inspection by its glossy 
appearance. Chemically it is distinguished by its behavior toward 
acetic acid. (See Urine.) 

Saliva. — The vomiting of pure saliva in the morning, upon ris- 
ing, is a fairly common symptom of chronic pharyngitis, which in 
turn frequently carries in its trail a chronic gastritis ; it constitutes 
the so-called vomitus matutinus. Saliva, like mucus, is, of course, 
always present in the gastric contents in small amounts. Larger 
amounts are usually referable to an increased secretion owing to the 



CHEMICAL EXAMINATION OF THE GASTRIC I VICE. 183 

existence of nausea. Chemically, saliva is best recognized by test- 
ing for the presence of the sulphocyanides. (See Saliva, p. 122.) 

Bile. — Bile is rarely observed in the gastric contents brought up 
by the stomach-tube, but is frequently seen in vomited matter, of 
which it may be said to be a constant constituent, whenever the 
vomiting has been very intense or frequently repeated. Its presence 
in the former case should always excite suspicion of the existence of 
stenosis of the descending or horizontal portion of the duodenum, or 
the beginning of the jejunum. This diagnosis becomes the more 
probable the more constant its presence. 

Pancreatic Juice. — Mixed with bile, there is probably always 
present some pancreatic juice, and it has even been suggested that 
the constant absence of this constituent, in the presence of bile, is 
strongly suggestive of pancreatic disease or of obstruction of the 
pancreatic duct (the ductus Wirsungianus). 

Blood. — The presence of unaltered blood in the gastric contents 
is usually recognized without difficulty. As marked alterations in 
color, varying from a deep red to a coffee or chocolate brown may 
occur, however, when free acids are present, it is at times necessary 
to resort to a more detailed examination. In order to recognize mere 
traces, when the macroscopic and even the microscopic examination 
do not point to the presence of blood, the method of Muller and 
Weber should be employed. Kuttner claims that he was thus able 
to demonstrate the presence of blood in numerous cases of chlorosis, 
in which other tests furnished negative results. I have been less 
successful in the disease in question, but admit that in cases of car- 
cinoma and ulcer of the stomach it is with this method often pos- 
sible to find traces of blood which would otherwise have remained 
unnoticed. 

Method of Muller and Weber : The gastric contents are treated 
with a few c.c. of strong acetic acid and extracted with ether. Should 
the ether not separate out in a clear layer after a few minutes, a few 
drops of alcohol are added. If the ether then remains colorless, no 
blood-pigment is present, while a brownish-red color indicates the 
presence of acetate of hsematin. As a similar but yellowish-brown 
and much less intense discoloration of the ether may be produced by 
other pigments, such as biliary coloring-matter, it is well, in doubt- 
ful cases, to test the ethereal extract with tincture of guaiacum. A 
positive result indicates the presence of blood coloring-matter. The 
same may be said if, upon spectroscopic examination of the ethereal 
extract, an absorption-band is discovered at the junction of the red 
and yellow. 

Hemorrhage from the stomach, hcematemesiSf may be observed in 
the most divers conditions. It is either dependent upon a primary 
disease of the organ, such as ulcer and carcinoma, or it occurs sec- 



184 THE GASTRIC JUICE AXD GASTRIC CONTENTS. 

ondarily to disease of other organs, leading to a hypersemic condi- 
tion of the gastric mucosa, such as the various forms of cardiac, 
renal, and hepatic disease, in connection with menstrual abnormal- 
ities, etc. In rnekena, purpura hemorrhagica, pernicious ansernia, 
etc., the cause of the hemorrhage cannot always be determined. It 
appears to be certain, however, that nervous influences may also take 
part in the causation of gastric hemorrhage. 

Pus. — The occurrence of pus in the vomited matter, referable to 
disease of the stomach itself, is uncommon. It is practically only 
seen in cases of phlegmonous and diphtheritic gastritis, and, as Strauss 
has recently pointed out, in carcinoma affecting the smaller curvature 
and the region of the fundus. In such cases it is not uncommon to ob- 
tain as much as one-half to two tablespoonfuls of a muco-purulent 
fluid from the non-digestiug organ. As the motor function in this 
form of carcinoma is often unimpaired the symptom may be of con- 
siderable value in diagnosis. The presence of larger quantities 
usually indicates the perforation into the stomach of an accumula- 
tion of pus from a neighboring organ. An abscess of the liver, a 
suppurative pancreatitis, an abscess of the colon, or a subphrenic 
abscess, may thus prove to be its primary source. When present in 
considerable amount pus is, of course, readily detected with the 
naked eye ; if any doubt should arise, a microscopic examination 
will determine the question. 

Stercoraceous Material. — Very important from a clinical stand- 
point is the vomiting of stercoraceous matter, which is notably ob- 
served in cases of ileus. This is usually recognized without diffi- 
culty by its odor, which is referable to the presence of skatol. If 
any doubt should arise, it is only necessary to distil the vomited 
matter after the addition of a little phosphoric acid, and to test for 
the presence of phenol, indol, and skatol in the distillate, as de- 
scribed in the chapter on Feces (see p. 202). When chiefly derived 
from the small intestine the vomited matter, according to v. Jaksch, 
will contain bile acids and biie pigment together with an abundance 
of fat, which may be detected by chemical or microscopic examina- 
tion. The reaction is usually alkaline or feebly acid. 

I have had occasion to examine the vomited matter of a patient 
in whom an almost complete obstruction existed immediately above 
the ileo-csecal valve ; the color of the material was a golden-yellow, 
the reaction neutral ; no bile pigment or biliary acids were found, 
while hydrobilirubin was present. Formed masses of feces, if found 
at all in the vomited matter under such conditions, are certainly of 
extreme rarity. 

Parasites. — Of parasites, ascarides, segments of taenia?, trichina?, 
anchylostoma duodenale, and oxyuris vermicularis are, at times, en- 
countered. The trichomonas vaginalis has also been seen in one 



MICROSCOPIC EXAMINATION OF THE GASTRIC CONTENTS. 185 

case of carcinoma of the oesophagus. For a description of these 
parasites see the chapter on the Feces. 

The Odor. — The odor of normal gastric juice is quite character- 
istic, suggesting the presence of some acid, which can be sharply dis- 
tinguished from the well-known odor referable to acetic acid or bu- 
tyric acid. If blood is present in large amounts, the vomited matter 
emits an odor which is so characteristic as never to be mistaken. A 
feculent^ odor is met with in cases of enterostenosis, or in the presence 
of an abnormal communication between the stomach and the small or 
large intestine. A putrid odor may be observed in cases of ulcerative 
carcinoma, pyloric stenosis referable to ulcer, simple carcinoma of 
the stomach, muscular hypertrophy of the pylorus, stenosis due to 
inflammatory adhesions, etc. In cases of phosphorus-poisoning the 
vomited matter emits an odor of garlic : the odor observed in ursemic 
conditions is referable to ammonia ; a carbolic-acid odor is met with 
in cases of poisoning with this substance. 

MICROSCOPIC EXAMINATION OF THE GASTRIC 
CONTENTS. 

In the gastric juice obtained from the non-digesting stomach the 
various morphologic constituents of mucus and saliva, which have 
been described elsewhere, are found. Microscopic particles of food, 
such as elastic tissue-fibres, starch-granules, fat-droplets, fatty acid 
crystals, vegetable and muscle-fibres, are, furthermore, quite con- 
stantly seen. Leucocytes and isolated nuclei are also observed ; 
the latter are set free by the action of the gastric juice upon the 
mucous corpuscles and epithelial cells. 

If gastric juice is allowed to stand, small tapioca-like bodies will 
collect at the bottom of the vessel, which upon microscopic exami- 
nation Avill be seen to contain numerous snail-shell-like formations, 
occurring either singly or collected in groups. These probably con- 
sist of altered mucin, as they can be artificially produced by adding 
a sufficient amount of dilute hydrochloric acid to saliva. Accord- 
ing to Boas, they are of no diagnostic significance. 

Epithelial cells, fragments of the epithelial lining of the ducts of 
glands, as well as goblet-cells, are not infrequently met with in the 
juice obtained from the non-digesting organ. In addition various 
micro-organisms, such as the leptothrix buccalis, bacillus subtilis, 
saccharomyces, micrococci, often arranged in the form of tetrahedra, 
Clostridium butyricum, etc., may be encountered. 

Among the bacteria which may be found in the gastric contents 
under pathologic conditions the bacillus, described by Boas and 
Opplcr, is undoubtedly the most important and has of late attracted 
much attention. It appears to be present quite constantly in ear- 



186 THE GASTRIC JUICE AND GASTRIC CONTENTS. 

cinoma, and is almost always absent in other diseases of the stom- 
ach. It is thought that the formation of lactic acid, which is like- 
wise so constantly observed in carcinoma, is largely and perhaps solely 
referable to its presence. The organism in question (Plate X.) 
is non-motile, and essentially characterized by its great length and by 
the fact that the individual bacilli are frequently seen joined together 
end to end, forming long threads and zig-zag lines, which are very 
characteristic. Often the entire field of vision is filled with dense 
conglomerations. Cultivation-experiments have thus far not been 
successful. The organism is readily stained with the usual anilin 
dyes. 

In vomited material containing biliary coloring-matter, leucin, ty- 
rosin, and cholesterin are also quite commonly observed, and may be 
recognized by the form of their crystals, as well as by their chemical 
reactions, which are described elsewhere. 

In pathologic conditions sarcinse, blood, pus, shreds of the mucous 
membrane of the stomach, carcinomatous material, etc., may also be 
present. 

Sarchice (Fig. 35) occur in the form of peculiar colonies of cocci, 
arranged in squares or tetrahedra, strongly resembling cotton-bales. 
Not infrequently they are encountered under normal conditions, but 
only in small numbers. In pathologic conditions, on the other hand, 
a drop of the gastric contents may constitute an almost pure culture. 
A case is even on record in which the pylorus had become entirely 
occluded by an inspissated mass of these organisms. Whenever pres- 
ent the existence of certain fermentative processes may be inferred. 

It is curious to note that in advanced cases of carcinoma of the stom- 
ach sarcinse are practically never seen, although the conditions are 
apparently most favorable for their development. Oppler was unable 
to find them twenty-four hours after their introduction in large num- 
bers and in pure culture. In cases of carcinoma of the curvatures and 
the walls, as also in advanced pyloric carcinoma, sarcinse w T ere never 
found, while they may be present in incipient cases of pyloric car- 
cinoma, so long as hydrochloric acid is secreted. 

The occurrence of blood and pus in the gastric contents has been 
considered (see p. 183). 

It not infrequently happens that small shreds of mucous mem- 
brane are brought away by the stomach-tube, and in cases of chronic 
gastritis, hyperchlorhydria not dependent upon ulcer, and in some of 
the neuroses this is indeed not at all uncommon. Boas even suggests 
that in the neuroses, where fragments of mucous membrane are so 
readily detached, this may possibly be etiologically connected with 
the formation of ulcers, and there can be no doubt that the mere 
action of the abdominal muscles exerted during the process of defeca- 
tion may be sufficient to detach such fragments. From the micro- 



PLATE X. 




L. SCHMIDT, FEC. 



The Boas-Oppler Bacillus, Stained with Methylene Blue. From a Case 

of Carcinoma of the Large Curvature of the Stomach. 

(Personal Observation.) 



MICROSCOPIC EXAMINATION OF THE GASTRIC CONTENTS. 187 

scopic appearance of the particles the diagnosis between a gastric 
neurosis and one of the various forms of chronic gastritis may be 
frequently made, and the same may be said to hold good in the 

Fig. 36. 




Cancer-cells from the gastric contents. (Ewald.) 

differential diagnosis between a true gastritis and a glandular in- 
sufficiency, referable to passive congestion of the gastric mucosa. 
At times also tumor particles are found in the gastric contents. In 



Fig. 37. 




A fragment of mucous membrane derived from the stomach. (Ewald.) 

the accompanying illustration (Fig. 36) a specimen obtained from a 
carcinomatous patient is represented, which is quite readily distin- 
guished from similar fragments of mucous membrane (Fig. 37). 



188 THE GASTRIC JUICE AND GASTRIC CONTENTS. 

EXAMINATION OF THE MOTOR POWER OF THE 
STOMACH. 

Under physiologic conditions the stomach should contain but few 
particles of food, or none at all, six hours after the ingestion of 
Riegel's meal, or one and one-half to one and three-quarter hours 
after that of Ewald. A delay in the removal of the gastric contents 
may be referable to the existence of a simple atony or to dilatation of 
the stomach. According to Boas, an atony may usually be diagnosed, 
if, following the exhibition of a supper consisting of bread and butter, 
cold meat, and a large cupful of tea, the stomach is found empty in 
the morning, providing, of course, that symptoms exist which point 
to atony or dilatation. It should be remembered, however, that in 
cases of acute and subacute gastritis, in the absence of a more serious 
lesion, food may be found in the stomach twenty-four hours after its 
ingestion. A dilatation may, on the other hand, be diagnosed if the 
stomach under the same conditions contains a considerable amount of 
food. In such cases it happens that not only remnants of the test- 
supper, but remains of meals taken one, two, three or even more 
days previously are found. The quantities, moreover, which may 
be obtained at the time of the examination are often surprisingly 
great, and may amount to sixteen pounds or more. Portel cites the 
case of the Due de Chausnes, one of Paris' greatest gourmands, whose 
stomach could hold 4.5 litres — i. e., 8 pints. 

The following methods may be employed for the purpose of test- 
ing the motor power of the stomach : 

Leube's Method. — The stomach is washed out six hours after 
the ingestion of Riegel's meal with about 1,000 c.c. of water. In 
the presence of only slight traces of food the motor power may be 
regarded as normal. This method is undoubtedly the most conve- 
nient for practical purposes. 

The Salol Test of Ewald and Sievers. — This test is based upon 
the observation that salol, a compound ether of salicylic acid, is de- 
composed into phenol and salicylic acid, only in an alkaline medium. 
As the salicylic acid is eliminated in the urine as salicyluric acid, it 
is possible to determine the time of the passage of the salol from 
the stomach into the small intestine. 

A capsule containing one gramme of salol is given to the patient 
immediately after his breakfast or dinner, when separate portions of 
urine, passed one-half, one hour, two hours, and twenty-four hours 
later, are tested by adding a small amount of a solution of 
the sesquichloride of iron. In the presence of salicyluric acid a 
violet color results. Under normal conditions a positive reaction is 
obtained after from forty-five to seventy-five minutes. A further 
delay may usually be regarded as indicating the existence of motor 



IS DIRECT EXAMINATION OF THE GASTRIC JUICE. 189 

insufficiency. If no result is obtained after twenty-four hours, a 
pyloric stenosis undoubtedly exists. Under normal conditions, fur- 
thermore, it will be observed that the salol elimination is completed 
after twenty-four hours, while in cases of dilatation of the stomach a 
positive reaction may still be obtained after thirty hours. It is thus 
possible to distinguish between dilatation and descent of the stomach. 
The test, while it is convenient and usually yields fair results, is 
not altogether reliable, as the decomposition of the salol may, at 
times, occur in the stomach, owing to the presence of alkaline mucus, 
or may be delayed in the intestines owing to the existence of acid 
fermentation, etc. 

EXAMINATION OF THE RESORPTIVE POWER OF THE 

STOMACH. 

To this end a capsule containing 0.2 gramme of potassium iodide 
is given to the patient shortly before a meal, and the saliva examined 
for the presence of potassium iodide at intervals of from two to three 
minutes. (See Saliva, p. 126.) 

Under normal conditions a violet color is obtained after from six 
and one-half to eleven minutes, and a bluish tint after from seven 
and one-half to fifteen minutes. In pathologic conditions a delayed 
reaction is observed in almost all diseases of the stomach, and is 
especially marked in cases of dilatation and carcinoma, less so in 
chronic gastritis, and variable in ulcer. 

Absolute conclusions, however, cannot be drawn from results thus 
obtained, as a normal reaction-time has also been observed in cases 
of dilatation and chronic gastritis. 

INDIRECT EXAMINATION OF THE GASTRIC JUICE. 

Giinzburg's Method. — In those cases in which for any reason the 
introduction of the stomach-tube is contraindicated or impractical 
the following method, suggested by Giinzburg, may be employed : 

Fig. 38. 




A fibrin-potassuun-iotliik' package of Giinzburg. 



A tablet of 0.2 to 0.3 gramme of potassium iodide is inserted into 
a piece of the thinnest possible, strongly vulcanized rubber-tubing. 
measuring about 2.5 cm. in length. The ends are folded as shown 
in Fig. 38, and the little package tied with three threads ot* fibrin, 



190 THE GASTRIC JUICE AND GASTRIC CONTENTS. 

hardened in alcohol. Every package should be examined before 
use, by immersion in warm Avater for several hours, to determine its 
tightness, testing for the presence of potassium iodide by means of 
starch-paper and fuming nitric acid. One of these packages is 
swallowed by the patient three-quarters to one hour after an Ewald's 
test-breakfast, and the saliva tested for potassium iodide at intervals 
of fifteen minutes, until a positive result is reached, or until six hours 
have elapsed. It is unnecessary to wait longer than six hours. In 
the presence of free hydrochloric acid the threads of fibrin are dis- 
solved and the potassium iodide absorbed. Under normal conditions 
a positive reaction is obtained after from one to one and three-quar- 
ter hours, while anachlorhydria undoubtedly exists if no result is 
obtained within five or six hours. In cases of hyperchlorhydria and 
hypochlorhydria the reaction is delayed for more than two to three 
hours. Giinzburg further advises that the resorption-test with potas- 
sium iodide be also made, and that the reaction-time be deducted 
from that taken up in the elimination of the iodide contained in the 
package. Several tests, moreover, should be made in the same 
case. 

I have had occasion to experiment with packages obtained from 
Germany, and manufactured according to the directions of Giinz- 
burg. 1 In most of the packages the threads of fibrin had become 
brittle and were broken in transit. The results obtained with about 
twenty intact specimens, however, were entirely satisfactory, and it 
is to be regretted that the packages cannot as yet be obtained in the 
American market. 

Similar packages have been constructed by Sahli. 

Reach has of late made use of barium iodate and the oxyiodate of 
bismuth for the same purpose, but without enclosing the substance 
in rubber. As hydrochloric acid only is capable of liberating the 
iodine from these bodies they may be employed instead of the Giinz- 
burg packages. As a result of his examinations he concludes that 
in the presence of hydrochloric acid iodine can thus be demonstrated 
in the saliva within eighty minutes. He finds, however, that at 
times the reaction occurs later than might have been supposed from 
the amount of hydrochloric acid found. 

The Author's Test. — Personal researches have led me to be- 
lieve that a close relation exists between the elimination of indican 
in the urine and the amount of free hydrochloric acid in the gastric 
contents. The results reached may be summarized as follows : 

1. Euchlorhydria is rarely associated with an increased elimina- 
tion of indican. 

2. In cases of simple neurotic hyperchlorhydria a subnormal or 
normal amount of indican is the rule. 

1 Gcthe Apotheke, Frankfurt a. M. 



INDIRECT EXAMINATION OF THE GASTRIC JUICE. 191 

3. In cases of hyperchlorhydria associated with ulcer an increased 
indicannria is quite constantly observed. 

4. Anachlorhydria, referable to organic lesions of the stomach, is 
almost invariably associated with a highly increased indicanuria. 

5. Hysterical anachlorhydria may be associated with the elimina- 
tion of a normal or increased amount of indican. 

6. In cases of hypochlorhydria increased indicanuria is the rule. 
Given as premises : 

1 . That a resorption of decomposing pus is not taking place any- 
where within the body, as such a process in itself is capable of caus- 
ing an increased elimination of indican. 

2. That a stenosis of the small intestine or a high degree of gas- 
tric atony does not exist. 

3. A normal mixed diet, containing no excessive amounts of red 
meat. (See Indicanuria.) 



CHAPTER IV. 
THE FECES. 

DEFINITION. 

The feces constitute a mixture of undigested particles of food and 
unabsorbed secretions of the gastro-intestinal tract, together with in- 
testinal mucus, epithelial cells, and bacteria. 

THE EXAMINATION OF NORMAL FECES. 

General Characteristics. 

Number of Stools. — The number of stools which may be passed 
in the twenty-four hours is even under physiologic conditions subject 
to wide variatiou, but usually constant for one and the same indi- 
vidual. One or two stools pro die may be regarded as normal. 
Exceptions, however, are frequent. Persons are thus met with who 
have but one stool every two to four days, and cases are on record 
in which one passage only occurred every seven to fourteen days, 
the individuals evidently enjoying perfect health. On the other 
hand, the number of stools may be increased to three and even four 
under strictly normal conditions. Hence the importance of accurately 
ascertaining the habitual number of stools in every individual. It 
would thus be manifestly wrong to regard the passage of three stools 
daily as diarrhoea, or the passage of only one stool in forty-eight 
hours as constipation, if this number has been habitual throughout 
life. 

Whether or not it is permissible to regard as normal those rare 
instances in which one stool only occurs every two to six weeks, or 
even less frequently, appears rather doubtful. 

Amount. — In those cases in which more than one or two stools 
occur in twenty-four hours it is well to ascertain the amount actually 
passed. The normal amount varies between 100 and 200 grammes. 
This quantity is increased by a diet rich in vegetable and starchy foods, 
and is diminished by one rich in animal proteids, so that 60 and 250 
grammes may be regarded as the extreme limits in health. Such 
amounts as 500 and 1,000 grammes are certainly abnormal. 

192 



THE EXAMINATION OF NORMAL FECES. 193 

Consistence and Form. — The consistence of a stool depends essen- 
tially upon the amount of water present, and hence upon the character 
of the food ingested, being softer with a purely vegetable diet (80- 
85 per cent, of water) than with a diet rich in animal proteids (60- 
65 per cent.). With a mixed diet the amount of water corresponds 
to about 75 per cent. As a general rule, normal stools exhibit the 
characteristic cylindrical form and are fairly firm. Mushy stools, 
however, are also seen quite frequently, and round, scybalous masses, 
although far more common in constipation, may likewise be observed 
in health. 

Odor. — The repugnant odor of the feces is, to a large extent, due 
to the presence of indol and skatol ; sulphuretted hydrogen, methane, 
and traces of phosphin may add still further to their disagreeable odor. 

Color. — The color of the feces varies, according to the nature of 
the food ingested, from a light to almost a blackish-brown, a firm 
stool being in general darker in color than a thin stool. A stool 
that has remained exposed to the air is also somewhat darker upon 
its outer surface than in its interior, owing to processes of oxidation. 
In nursing-infants, in consequence of the exclusive ingestion of milk, 
the color is light yellow. 

Under normal conditions the color is never due to native biliary 
coloring-matter, the presence of this substance being always indica- 
tive of some pathologic process, but is largely dependent upon the 
presence of hydrobilirubin — i. e., reduced bilirubin. It is, further- 
more, influenced by the nature of the food, chlorophyll tending to 
produce a greenish color, starches a yellowish tinge. If much blood 
is present in the food, the feces may be almost black, owing to the 
formation of hsematin. Huckleberries and red wine likewise pro- 
duce a blackish color, chocolate and cocoa a gray ; preparations of 
iron, manganese, and bismuth color the feces dark brown or black, 
owing to the formation of the sulphides of these metals ; the green 
color of calomel stools was formerly supposed to be due to the 
formation of a sulphide, but is more likely caused by the presence of 
biliverdin. Santonin, rheum, and senna produce a yellow color. 

Macroscopic Constituents. 

Alimentary Detritus. — Upon further examination of the feces 
it is possible to find, visible to the naked eye, undigested particles of 
food, which are partly indigestible and partly digestible, such as 
stones of cherries, grape-seeds, woody vegetable fibre, the skins of 
berries, large pieces of connective tissue, undigested pieces of apples, 
pears, potatoes, grains of corn, etc. The latter are found in abund- 
ance when the food is insufficiently masticated or taken in excessive 
amounts. 
13 



194 THE FECES. 

Flakes of casein, recognizable with the naked eye, are also fre- 
quently seen. Care should be taken not to confound these with par- 
ticles of stool composed of fatty acid crystals. This mistake is 
often made, and can readily be avoided by a microscopic or chemical 
examination (see p. 214). 

Foreign Bodies. — In children, the insane, in cases of hysteria, 
and even in people who are apparently possessed of their normal 
senses, the physician must be prepared to find at times all kinds of 
foreign bodies, such as pins, coins, buttons, false teeth, tooth-plates 
with ragged edges, and even dirk-knives, all of which have been 
known to pass through the alimentary canal with perfect safety. It 
must not be forgotten, however, that in certain cases of hysteria 
bodies may be sIioavu by patients which they claim have passed by 
the rectum, but which have been willfully added to the stools, such 
as snakes, frogs, etc. 

Microscopic Constituents. 

Constituents Derived from Food. — Microscopically indigestible 
and undigested constituents of food may be seen (Fig. 39), such as 
the framework of vegetable material, sometimes still containing 
starch-granules or remnants of chlorophyll ; muscle-fibres, usually 
colored yellow and more or less altered in structure. Elastic-tissue 
fibres are readily recognized by their double contour and bold out- 
lines. Connective-tissue fibres of the white fibrous variety can also 
generally be distinguished ; when present in large quantities, how- 
ever, they are usually indicative of some digestive derangement, 
unless they are observed following the ingestion of a meal particu- 
larly rich in meat. Flakes of casein are also frequently seen. 

Muscle-fibres are found in every stool whenever meat has been 
eaten. Under normal conditions, however, they are not numerous, 
unless particularly large quantities have been ingested. Their ap- 
pearance under the microscope may vary considerably. On the one 
hand, fibres are met with which still retain their characteristic 
features ; others are split up either partially or entirely into the 
well-known disks ; but more common than both are more or less 
roundish, yellow, apparently homogeneous fragments, which at first 
sight do not resemble muscle-fibres in the least. Upon closer in- 
vestigation, however, their true nature will become apparent. It 
will then be seen that two of the sides in some portions at least are 
more or less parallel, and if the specimen is examined with an oil- 
immersion lens some traces of cross-striation can probably always 
be discovered. 

Isolated starch granules are scarcely ever found under normal 
conditions, excepting in young children who have been fed with much 
starchy material. Starch-granules enclosed in vegetable cells are 



THE EXAMINATION OE NORMAL FECES. 



195 



likewise not found as a general rule, but are more common than the 
isolated granules. The presence of either in large numbers is usually 
indicative of the existence of some pathologic condition affecting the 
gastro-intestinal tract. Their presence is easily recognized by treat- 
ing microscopic preparations with a solution of iodo-potassic iodide 
(Lugol's solution), when the granules or fragments Avill assume a 
blue color. 

The presence of fat in the feces is quite constant, even in health. 
It may occur in the form of needle-like crystals, as fat-droplets, or 
as polygonal masses which are highly refractive and often colored 
yellow or a yellowish-red. Their true nature is easily recognized by 
adding a drop of concentrated sulphuric acid and heating, when they 
are transformed into the characteristic fat-droplets. 

Fig. 39. 




Collective view of the feces. (Eye-piece III., objective 8 a, Eeichert.) a, muscle-fibres; b, con- 
nective tissue ; c, epithelium ; d, white blood-corpuscles ; e, spiral cells ; /, i, various vegetable 
cells ; k, triple phosphate crystals in a mass of various micro-organisms ; I, diatoms, (v. Jaksch. ) 

Morphologic Elements Derived from the Alimentary Canal. 
— 1. Epithelial cells. Well-preserved cylindrical or goblet cells are 
only exceptionally found in the feces, while transition forms from 
the normal cells to mere spindles, in which a nucleus can no longer 
be recognized, are quite constantly observed. These degenerative 
changes, according to Nothnagel, are the result of an abstraction of 
water from the cells, which may alter their appearance to an extent 
that only the experienced eye is capable of recognizing their true 
character. Pavement epithelial cells, when present, are derived 
from the anal orifice. 

2. Leucocytes are almost always absent in normal stools or present 
only in very small numbers. 

3. Red blood-corpuscles in very small numbers are occasionally 
observed under apparently normal conditions, but are then o( no 
significance. 



196 



THE FECES. 



4. In every stool a large number of structureless granules may 
be seen, lying either by themselves or collected into heaps ; they are 
designated as detritus. 

Crystals. — Needle-like crystals of free fatty acids, and the calcium 
and magnesium salts of the higher members of this group, occurring 
either single or arranged in sheaves, may be found in every stool 
(Fig. 40). They are of no significance, unless present in very large 
numbers. Xothnagei speaks of the frequent occurrence of certain 
calcium salts (of fatty acids, as he believes) in normal as well as 
pathologic stools. He states that they are almost always bile-stained 
and occur in irregular, sometimes elliptical, oval, or circular masses, 
in which a crystalline structure cannot be distinguished. They are 
apparently of no importance. Quite common, also, are crystals of 
neutral calcium phosphate and ammonio-magnesium phosphate, the 

Fig. 40. 






Jmwk 

Fatty crystals obtained from the feces. 

former occurring in the form of more or less well-defined wedge- 
shaped crystals, collected into rosettes, the latter presenting the 
well-known coffin-shape when the stool is mushy, while in firm 
stools irregular fragments are mostly found. At one time the 
ammonio-magnesium phosphate crystals were supposed to be charac- 
teristic of typhoid stools, but it is now known that they occur in 
normal feces, as well as under the most varied pathologic conditions. 
Their presence is of no diagnostic significance. It is important to 
note that the neutral phosphates are never stained by bile-pigment, 
and the triple phosphates only in rare instances. Both are easily 
osluble in acetic acid. Crystals of oxalate of calcium may be found 
in abundance following the ingestion of certain vegetables, such as 



THE EXAMINATION OF NORMAL FECES. 197 

sorrel and spinach. They are usually found embedded in the vege- 
table debris. They are readily recognized by their characteristic 
envelope- form, their insolubility in acetic acid, and their solubility 
in hydrochloric acid. Not infrequently they are bile-stained. 

Lactate of calcium is frequently seen in the stools of children receiv- 
ing a milk-diet ; they occur in the form of sheaves composed of radi- 
ating needles. Calcium carbonate is rarely observed, but occasion- 
ally occurs in the form of amorphous granules or dumb-bell shaped 
crystals. Calcium sulphate crystals are likewise rare, but may be 
produced artificially by the addition of sulphuric acid, when beauti- 
ful needles and platelets may be observed. Cholesterin, while always 
present in solution, is rarely observed in crystalline form (Fig. 41). 
I have only found it twice in several hundred examinations. Hsema- 
toidin crystals are never found in normal stools. Charcot-Leyden 
crystals may be found under pathologic conditions ; according to my 
experience they are never seen in normal stools. 

Parasites. — The parasites which occur in normal feces may be 
divided into vegetable and animal parasites. 

Vegetable Parasites. — These are always present in enormous 
numbers. What relation they bear to the process of digestion is 
still an open question. The idea held by Pasteur and many others, 
that animal life cannot go on in the absence of bacteria from the di- 
gestive tract has recently been disproved by Nuttall and Tierfelder. 
A guinea-pig, removed by Cesarean section from the uterus of the 
mother-animal, under antiseptic precautions, was placed in a ster- 
ilized glass cage and nourished for a week with sterilized food. The 
air which the animal breathed was likewise sterilized. During this 
week the animal consumed about 330 c.c. of milk and appeared to 
be normal in every respect. At the expiration of the week it was 
killed, when a microscopic examination of the intestinal contents re- 
vealed the entire absence of bacteria. Culture-experiments also were 
negative. 

Macfayden, Nencki, and Sieber likewise found that their now so 
often quoted fistula patient continued in good health, and even 
gained flesh, although the entire large intestine, in which bacterial 
activity is always greatest, was thrown out entirely for a period of 
many weeks. 

Fungi. — Fungi, with the exception, perhaps, of the oidium albi- 
cans, which has at times been observed, are but rarely found in the 
feces. 

Schizomycetes. — Saccharomyces cerevisise belongs to the normal 
constituents of the feces, and is found in its characteristic forms. 
three or four buds, however, being but ordinarily observed. Owing 
to the glycogen present in their substance, they assume a mahogany 
color when treated with a sodium of iodo-potassie iodide. They 



198 THE FECES. 

should not be confounded with a class of bacteria which closely re- 
semble the saccharomyces in general appearance, but are colored blue, 
when treated in the same manner (see below). 

Bacteria. — The bacteria are the micro-organisms xari^oyijv 
which are found in the feces. Their number is truly enormous. 
SucksdorfF thus found in his own person that on an average 
53,124,000,000 were eliminated in the twenty- four hours under 
normal conditions. About 97 per cent, of these are directly derived 
from the ingested food, and the remaining 3 per cent, from swal- 
lowed saliva. If we recall the strongly bactericidal power of the 
gastric juice, such an observation must at first sight appear most 
surprising. It should be remembered, however, that the spores of 
the bacteria are far less susceptible to the action of the hydrochloric 
acid, and that large amounts of the ingesta are carried into the small 
intestine at a time already, when hydrochloric acid has not as yet 
appeared in the free state. 

On the whole, the bacteriologic flora of the intestinal contents is 
fairly constant, but, as in the other cavities and channels of the 
body where bacteria are invariably met with, transient guests are 
also not uncommon. The majority of the bacteria which are here 
encountered are, as a general rule, harmless, but it is important to 
note that under suitable conditions a number of these may develop 
pathogenic properties. Roughly speaking, the bacteria which may 
be normally found in the feces can be divided into two classes. 
Those belonging to the first order are stained a yellow or a yel- 
lowish-brown with the iodo-potassic iodide, while those belonging to 
the second class are colored blue or violet by the same reagent. To 
the former belong the bacterium termo, the bacillus subtilis, and a 
large number of micrococci ; into a description of these it is not 
necessary to enter at this place. Under the second heading v. Jaksch 
describes the following forms : 

1. Micrococci occurring in the zooglcea stage, which are colored 
a violet-red. 

2. Short, thin rods, tapering slightly at both ends, and in their 
microscopic appearance much resembling the bacillus of the septi- 
caemia of mice ; sometimes they contain one or two little bodies, 
which are not stained by the reagent. 

3. Short or long rods, which resemble the leptothrix buccalis in 
their behavior toward iodo-potassic iodide. 

4. Bacilli resembling the bacillus subtilis. 

5. Bacillus butyricus. This micro-organism, according to Brieger, 
is the cause of butyric-acid fermentation. It occurs in the form of 
broad rods with rounded-off extremities, but may also be elliptical 
or spindle-shaped. With Lugol's solution it is colored blue or 
violet, either entirely or only in its central portion. 



THE EXAMINATION OF NORMAL FECES. 199 

6. Large round forms, characterized, when unstained, by a pale 
lustre, and which very much resemble yeast-cells (see above). 

7. Micrococci, which assume a reddish, but not very pronounced 
tint. 

It should be mentioned that this second class of micro-organisms 
is not so largely represented in the feces as the first. 

To speak more specifically, the following bacteria have thus far 
been isolated from the feces : the bacillus coli communis, bacterium 
lactis aerogenes, bacillus subtilis, proteus vulgaris, bacillus putrificus 
coli, bacillus liquefaciens ilei, bacterium ilei, bacterium ovale ilei, 
bacillus gracilis ilei, the veil bacillus of Escherich, bacillus butyricus, 
bacillus Utpadel ; streptococcus coli gracilis, streptococcus coli brevis, 
streptococcus liquefaciens ilei, streptococcus pyogenes duodenalis, 
staphylococcus liquefaciens albus, staphylococcus liquefaciens flavus, 
micrococcus ovalis, the porcelain-coccus of Escherich, tetradenococcus. 
In addition various other bacteria have been found, but have not as 
yet been obtained in pure culture. This is true more particularly 
of certain forms of spirillum. 

The specific pathogenic bacteria which may be fouucl in the feces, 
as well as those above mentioned, which may at times develop patho- 
genic properties, will be described in detail later on. 

Animal parasites are probably never present under strictly normal 
conditions. 

Chemistry of Normal Feces. 

Reaction. — The reaction of the feces is usually alkaline, sometimes 
neutral, rarely acid, the alkalinity being due to ammoniacal fermen- 
tation, the acidity to lactic- and butyric-acid fermentation, taking 
place in the intestines. In infants the stools are normally acid. 

General Composition. — The following table, taken from Grautier, 
will give an idea of the composition of fresh feces, calculated for 
1,000 parts by weight : 





Adult man. 


Suckling 


Water 


. 733.00 


851.3 


Solids 


. 267.00 


148.7 


Total organic material 


. 208.75 


137.1 1 


Total mineral material 


. 10. 95* 


13.0 


Alimentary residue 


. 83.00 




organic material yielded : 






Aqueous extract . 


. 53.40 


h\\.o 


Alcoholic extract 


. 41.05 


8.20 


Ethereal extract . 


. 30. 70 


17. 6 3 



1 Including 54 parts of mucin, epithelium, and calcareous sal 

2 Not comprising earthy phosphates. 

3 Of this, 3. 'J is cholesterm. 



200 THE FECES. 

In addition, there are gases, which vary in quantity according to the 
nature of the food ingested, such articles as beans, heavy bread, pota- 
toes, etc., increasing the amount very considerably. 





Milk diet. 


Meat diet. 


Vegetable diet. 




Per cent. 


Per cent. 


Per cent. 


Carbon dioxide 


. 9-16 


8-13 


21-34 


Hydrogen 


. 43-54 


0.7-3 


1.5-4 


Marsh gas 


0.09 


26-37 


44-55 


Nitrogen 


. 36-38 


45-64 


10-19 



Of these gases, carbon dioxide is partly referable to alcoholic and 
butyric-acid fermentation, and partly to albuminous putrefaction, 
taking place in the intestines. Marsh gas is formed during the fer- 
mentation of cellulose, while the nitrogen has been partly swallowed 
and is partly referable to albuminous putrefaction. A portion also 
is probably derived from the blood, and it may be mentioned in this 
connection that the enormous quantities of carbon dioxide so often 
discharged in cases of hysteria, are undoubtedly referable to this 
source, the gas passing from the blood through the gastro-intestinal 
mucous membrane into the stomach and intestines. 

In order to give a general idea of the chemical constituents of the 
feces these may be divided into : 

1. Food-material, which could be assimilated, but which was taken 
in excess, such as starches, fats, and a small amount of non-assimi- 
lated albuminous material. 

2. Indigestible substances, such as chlorophyll, gums, pectic pro- 
ducts, resins, various coloring-matters, nucleins, chitin, and insolu- 
ble salts, viz, silicates, sulphates, earthy phosphates, ammonio-mag- 
nesium phosphate, etc. 

3. Products derived from the digestive canal, as mucus, partly 
transformed biliary acids, dyslysin, cholesterin, lecithin. 

4. Substances in process of absorption, as emulsified fats, fatty 
acids, leucin, and biliary acids. 

5. Products of decomposition, referable to microbic activity, such 
as fatty acids, comprising the entire series from acetic to palmitic 
acid, the latter being especially abundant ; butyric and iso-butyric 
acid, lactic acid, phenol, cresol, indol, skatol, excretin, amido-acids, 
and acidamides, leucin and tyrosin, phenyl-proprionic, phenyl-acetic, 
hydroparacumaric, and parahydroxylphenyl-acetic acid, ammonium 
carbonate and ammonium sulphide. 

6. Products of metabolism eliminated through the intestines : 
urea, uric acid, and xanthin bases. 

7. Pigments : stercobilin, hsematin, hydrobilirubin, coloring-mat- 
ter derived from the blood, and, in abnormal conditions, bile-pig- 
ments. 

8. Water. 



THE EXAMINATION OF NORMAL FECES. 201 

9. Gases, as carbon dioxide, marsh gas, hydrogen, and nitrogen. 

The study of these substances as a whole, as well as in detail, 
is of great importance, not only from the standpoint of the physiol- 
ogist, but also from that of the clinician, giving, together with a 
careful urinary analysis, the clearest idea of the metabolic processes 
taking place in the body. 

The chemical study of the feces, however, has so far received but 
little attention, and data of practical importance have scarcely been 
obtained from the work accomplished. The field is nevertheless an 
important one. 

It is impossible to give here a detailed description of the various 
chemical constituents which have been mentioned. Only the most 
important ones and those especially interesting from a physiologic 
and pathologic standpoint will be considered. 

Phenol, Indol, and Skatol. — Tyrosin, produced during the proc- 
ess of albuminous putrefaction, and also during tryptic digestion, 
must be regarded as the mother-substance of phenol, cresol, indol, 
and skatol. It may be represented by the formula : 

/CH 2 - (NH 2 ) - COOH 
C 6 h/ = C 9 H n M) 3 . 

The relation which phenol, cresol, indol, and skatol bear to tyro- 
sin may be seen from the following formula? : 

CH 3 

C 

C 6 H 4 CH =C 9 H 9 N (Skatol). 

\/ 
NH 

CH 

/^ 
C 6 H 4 CH =C S H 7 N (Indol). 

\/ 

NH 

C 6 H 4 .CH,.OH=C 7 H 8 (Cresol). 
C 6 H 5 .OH =C 6 H e O (Phenol). 

As the tyrosin, however, is very readily decomposed, it is usually 
not found in the feces, but the products of its decomposition instead. 
viz, the phenols, indol, and skatol. 

As will be seen more especially in the chapter on Urine, these 
bodies, after having undergone oxidation, unite with sulphuric acid. 
or, if this is not present in sufficient amount, with glycuronic acid. 



202 THE FECES. 

and are excreted as phenol, indoxyl, and skatoxyl sulphates or gly- 
curonates in the urine. In the feces, on the other hand, phenol, 
cresol, indol, and skatol are found as such. From these they may 
be obtained in the following manner : 

The feces are diluted with water, acidified with phosphoric acid, 
and distilled. The volatile fatty acids present, together with phenol, 
indol, and skatol, pass over. The distillate is then neutralized with 
sodium carbonate and again distilled. During this process phenol, 
indol, and skatol pass over, the fatty acids remaining behind as 
sodium salts. In order to separate the phenol from indol and skatol 
the distillate is alkalinized with potassium hydrate and again distilled. 
The phenol now remains behind, and may be obtained in pure form 
by distilling with sulphuric acid ; in this final distillate its presence 
may be demonstrated by the following reactions : 

1. With perchloride of iron phenol yields an amethyst-blue color. 

2. With bromine- water a crystalline precipitate of tribromophenol 
is obtained. 

3. Treated with Millon's reagent — i. e., the acid nitrate of mer- 
cury — a red color develops. 

Indol and skatol pass over after treating the above mixture of 
the three with potassium hydrate and distilling. These two bodies 
may then be separated from each other by taking advantage of their 
different degrees of solubility in water. 

Indol forms small plates, melting at 52° C, which are easily soluble 
in hot water, alcohol, and ether ; its odor is feculent. 

Reactions of indol : 1. When treated with nitric acid and a little 
sodium nitrite a crystalline, red precipitate of the nitrate of nitroso- 
indol is obtained. 2. A small piece of pine- wood, moistened with 
an alcoholic solution of indol, acidified with hydrochloric acid, is 
colored a cherry red. 

Skatol crystallizes in plates, which melt at 95° C. They are soluble 
with more difficulty in water than indol, and emit a feculent odor. 

Reactions of skatol : 1. With nitric acid and sodium nitrite only 
a milky cloudiness results. 2. Pure skatol does not yield any color 
with pine-wood moistened with hydrochloric acid ; but if a bit of 
the wood is saturated with a dilute alcoholic solution of skatol and 
then immersed in strong hydrochloric acid, it assumes a cherry-red 
and later a bluish-violet color. 3. With nitric acid of a specific 
gravity of 1.2 it gives a marked xanthoproteic reaction on boiling — 
i. e., a yellow color which turns to orange upon the addition of an 
excess of ammonia. 

The determination of cresol in the presence of phenol, together 
with which it is obtained, is, when only small quantities of these 
substances are present, a difficult matter. They may be separated 
from each other by transforming both into their sulpho-acids, the 



Formic acid 


H.COOH . 


Acetic " 


CH3.COOH 


Proprionic acid 


CH 3 .CH 2 .COOH 


Butyric 


CH,.(CH 2 ) 2 .COOH 


Isobutyric ' ' 


(CH 3 ) 2 .CH.COOH 


Valerianic " 


CH 3 .(CH 2 ) 3 .COOH 


Caproic 


CH 3 .(CH 2 ) 4 .COOH 


Capric 


CH 3 .(CH 2 ) 8 .COOH 


Palmitic ' ' 


CH 3 .(CH 2 ) H .COOH 


Stearic 


CH 3 .(CH 2 ) 16 .COOH 



THE EXAMINATION OF NORMAL FECES. 203 

barium salt of para-sulpho-phenol being practically insoluble in 
barium hydrate. 

Fatty Acids. — The fatty acids present in the feces, as well as the 
relation existing between these, are shown in the table below. The 
formula C n H 2n+1 COOH or C n H 2n 2 expresses their general struc- 
ture. 

. C H 2 2 

. C 2 H 4 2 

• C 3 H 6 2 

. C 4 H 8 2 

• • • C 4 H 8 2 

. . . C 5 H 10 O 2 

. • • C 6 H l2 2 



These acids are derived partly from fats, partly from carbohy- 
drates, and to some extent also from proteids. 

Separation of the fatty acids from the feces : If the distillate, neu- 
tralized with sodium carbonate, referred to in the above method, is 
again distilled, the sodium salts of the fatty acids remain behind : 

2C 13 H 31 .COOH + Na 2 C0 3 = 2C 15 H 31 . COO. Na -f H 2 + C0 2 . 

The solution is then evaporated to dryness on a water-bath, the 
residue extracted with alcohol, the alcohol evaporated, and the final 
residue dissolved in water. This solution may now be further ex- 
amined. In order to separate the different fatty acids from each 
other it is best, if the quantity is sufficiently large, to transform 
them into their silver or barium salts, and to separate these by their 
varying degrees of solubility in water, or by fractional distillation. 

General properties of the fatty acids : They are all monobasic, 
soluble in water, alcohol, and ether. Their alkaline salts are readily 
soluble in water and alcohol, but insoluble in ether. The silver salts 
are dissolved with difficulty. 

1. Formic acid is a colorless liquid, of a penetrating odor, boiling 
at 100° C. A concentrated solution of its alkaline salts is precipi- 
tated by silver nitrate ; the silver salt becomes black on standing, 
and reduction takes place at once upon the application of heat. 
Treated with perchloride of iron in a neutral solution it yields a 
blood-red color, which disappears on boiling, while a rust-colored 
precipitate is formed at the same time. 

2. Acetic acid is a liquid of a pungent odor, which boils at 
119° C. After neutralization a blood-red color is obtained on the 
addition of perchloride of iron. Neutral solutions o( its salts with 
the alkalies yield a precipitate with nitrate of silver, which is soluble 
in hot water, without reduction taking place. 



204 THE FECES. 

3. Proprionic acid is an oily fluid, boiling at 117° C. With per- 
chloride of iron no red color results ; with silver nitrate it behaves 
like formic acid. 

4. Butyric acid is an oily liquid, boiling at 137° C. ; its odor is 
similar to that of rancid butter. Its salts, when treated with an 
acid, give off the characteristic odor ; with perchloride of iron it 
yields no red color ; with silver nitrate its alkaline salts form a crys- 
talline precipitate which is insoluble in cold water. 

5. Valerianic acid boils at 176.3° C, and has a penetrating, dis- 
agreeable odor. Its silver salt crystallizes in plates, which are solu- 
ble with difficulty. 

Cholesterin. — Cholesterin (C >(3 H^O) occurs in small amounts in 
almost all animal fluids. It is also found in various tissues of the 
body, especially in the brain. Its origin and mode of formation in 
the various organs of the body, as well as the cause of its presence 
in the alimentary canal, are as yet unknown. It crystallizes in 
colorless, transparent plates, the margins and augles of which usually 
present a ragged appearance (Fig. 41). It is soluble in water, dilute 
acids, and alkalies. In boiling alcohol it is readily soluble and 
crystallizes out from this solution on cooling ; it is likewise easily 
soluble in ether, chloroform, and benzol. 

In order to obtain cholesterin from the feces, in which it is always 
present, though rarely in crystalline form, the fatty acids, phenols, 
indol, and skatol must first be distilled off, as described, when the 




Cholesterin crystals. 



residue is strongly acidified with sulphuric acid, extracted with 
alcohol, and then with ether. The ethereal extract is filtered, the 
ether distilled off, and the residue digested with carbonate of sodium, 
in order to transform any fatty acids which may still be present into 
their salts. This mixture is then evaporated to dryness, and again 



THE EXAMINATION OF NORMAL FECES. 205 

extracted with ether. The alcoholic extract above mentioned is also 
filtered, supersaturated with sodium carbonate, the alcohol distilled 
off, the residue dissolved in water, and likewise extracted with ether. 
In the watery alkaline residue there remain bile acids, oleic, palmitic, 
and stearic acids, which can be separated by transforming them into 
their barium salts. The cholesterin and fats pass over into the 
ether. This is distilled off and the residue treated with an alcoholic 
solution of potassium hydrate. The alcohol is evaporated on a 
water-bath, the remaining liquid diluted with water, and again ex- 
tracted with ether. The fats remain in the aqueous solution as 
soaps, while the cholesterin has passed into the ether. 

Tests for cholesterin : 1, Under the microscope add a drop of 
concentrated sulphuric acid to some of the crystals ; they gradually 
disappear, the edges assuming a yellowish-red color. 

2. Dissolve a few crystals in chloroform, add concentrated sul- 
phuric acid, and shake the mixture : the chloroform assumes a blood- 
red to a purplish-red color, while the sulphuric acid at the same time 
shows marked fluorescence. 

The solution of soaps obtained above is acidified with dilute sul- 
phuric acid, when the fatty acids, which have separated out, may be 
filtered off and identified individually by their boiling points and the 
analysis of their barium salts. 

The final filtrate, when neutralized with ammonium hydrate, con- 
tains glycerin. 

The Biliary Acids. — The biliary acids found in the feces are : 
Glycocholic acid (C 2r H 43 N0 6 ), taurocholic acid (C 26 H 45 NSO_), and 
cholalic acid (C 24 H 4 5 ). 

The two former occur normally in the bile, and can be decomposed 
into cholalic acid and glycocoll, and cholalic acid and taurin respec- 
tively ; as this process of decomposition takes place ordinarily in the 
intestines, the third acid — i. e., cholalic acid — is always found in the 
feces. 

In order to demonstrate the biliary acids, the fatty acids, phenols, 
indol, and skatol are first removed by distillation with phosphoric 
acid. The residue is taken up with water and boiled, and the filtered 
liquid precipitated with acetate of lead and a little ammonium hy- 
drate. The biliary salts of lead are contained in the precipitate, 
from which they can be removed by washing with water and finally 
boiling the precipitate with alcohol. The washings are filtered and 
the lead salts transformed into sodium salts by treating the nitrate 
with sodium carbonate. After further filtration the filtrate is evapo- 
rated to dryness and the residue extracted with hot alcohol. Upon 
evaporation the salts of the acids sometimes crystallize out as siu-h, 
while more often a dirty amorphous precipitate 1 is obtained, which 
may be rendered crystalline by treating with ether. The amor- 



206 THE FECES. 

phous residue, however, can be employed for making the necessary 
tests. 

Pettenkofer's test : A small amount of the substance is dissolved 
in water, and treated with two-thirds of its volume of concentrated 
sulphuric acid, care being taken that the temperature does not exceed 
60° or 70° C. "While stirring, a 10-per-cent. solution of cane-sugar 
is added, drop by drop. If biliary acids are present, the solution 
assumes a beautiful red color, which on standing turns a bluish-violet. 
This test depends upon the action of furfurol, derived from the sul- 
phuric acid and cane-sugar, upon the biliary acids. 

Pigments. — Among the pigments present in normal feces ster- 
cobilin and hydrobilirubin must be considered. 

Stercobilin is spoken of by Gautier as the principal coloring-mat- 
ter of the feces, and is derived from bilirubin by a process of reduc- 
tion. Owing to its great similarity to hydrobilirubin it has even 
been said to be identical with this. It has been obtained by extract- 
ing the feces with acidulated alcohol ; this extract is diluted with 
water and shaken with chloroform, which dissolves the pigment. 

The difference between stercobilin and hydrobilirubin appears to 
be a spectroscopic one, the spectrum of the former, when treated 
with chloride of zinc and ammonium hydrate, giving rise to four 
bands of absorption, while only three are obtained with hydrobili- 
rubin. The pronounced green fluorescence, however, is common to 
both. 

By means of the spectroscope it is also possible to distinguish be- 
tween normal urobilin and stercobilin ; the latter is possibly identi- 
cal with the pathologic urobilin observed in febrile urines. 

Hydrobilirubin is identical with the urobilin of Jaffe and the febrile 
urobilin of MacMunn, and shows three bands of absorption, as has 
just been mentioned. Its chemical formula is C.^H 4(l X 4 0_. According 
to v. Jaksch, it is obtained in the same manner as stercobilin. 

PATHOLOGY OF THE FECES. 

General Characteristics. 

Number of Stools. — As has been pointed out (p. 192), one or 
two stools in the twenty-four hours may be considered as normal. 
Individual peculiarities, however, must be taken into consideration. 

As the consistence of the stools is altered in diarrhoea, this condi- 
tion may be defined as one in which too frequent and liquid passages 
occur, while the reverse holds good for constipation, the consistence 
of the stools in this condition being usually also altered. 

The term obstruction, on the other hand, denotes a state of affairs 
in which no stools are voided. In a general way it may be said that 



PATHOLOGY OF THE FECES. 207 

whatever causes give rise to increased peristalsis likewise produce 
diarrhoea, and that whatever causes diminish peristalsis give rise to 
constipation. In the former condition the number of stools may vary 
from one to thirty, forty, or even fifty in the twenty-four hours, as 
in Asiatic cholera. The consistence of the stool when only one is 
passed in the twenty-four hours will, of course, decide the question 
whether the case should be regarded as one of diarrhoea or not. One 
stool passed in the twenty-four hours may under certain conditions 
be regarded as a symptom of constipation, but more commonly this 
term is applied to a condition in which a stool occurs only every 
two, three, four, or more days. 

Consistence and Form. — The consistence of the stools may 
undergo variations, which run a course parallel to their number. 
They may be thin, mushy, and even watery. 

In constipation, on the other hand, owing to an increased absorp- 
tion of water, the feces may be passed as very hard and perfectly 
dry, roundish, scybalous masses, the rotundity of which is undoubt- 
edly referable to their long sojourn in the haustraof the colon. The 
individual scybala usually vary in size from that of a hazelnut to that 
of a walnut, and are frequently provided with one or two indentations 
which represent impressions of the taeniae of the colon. Still smaller 
masses, closely resembling the dejecta of sheep, may also be seen. 
Their presence was formerly regarded as characteristic of stricture 
of the colon, but they are likewise found in ordinary cases of chronic 
constipation. Fecal ribbons, and columns of the diameter of a pen- 
cil are found in cases of enterospasm of neurotic origin, as well as 
in stricture of the colon. 

Amount. — The absolute amount of feces voided in the twenty- 
four hours bears an inverse relation to the number of stools and their 
consistence, providing, of course, that no abnormally large ingestion 
of food has occurred. In that case an abnormally large stool of 
moderate firmness may be passed. Two exceptions must, however, 
be noted to this rule — i. e., the passage of large quantities of firm 
feces, following an attack of constipation of long duration or an 
attack of severe obstruction. 

Odor. — As the normal oifensive odor of the feces is largely due to 
products of intestinal putrefaction, an increase in this respect will 
naturally be referable to conditions in which the putrefactive proc- 
esses are increased. A most disagreeable odor is thus met with in 
the so-called acholic stools. The odor of fatty acids is observed in 
the lighter grades of infantile diarrhoea, while a markedly putrid 
odor is associated with its severer forms. A very characteristic, 
sperm-like odor is further noted in the stools of cholera owing to the 
presence of considerable quantities of cadaverin. A truly rotten 
stench is present in the gangrenous form of dysentery, and in careino- 



208 THE FECES. 

matous and syphilitic ulceration of the rectum. An ammoniacal odor 
is due to an admixture of urine undergoing ammoniacal decomposition. 

Reaction. — The reaction of the stools is variable under patho- 
logic conditions and of no diagnostic importance. In typhoid fever, 
it is true, an alkaline reaction is so constantly met with that this 
symptom could possibly be of some value in doubtful cases. Un- 
fortunately, however, it may also be neutral, amphoteric, and even 
acid. In acute infantile diarrhoea an acid reaction is the rule, but 
exceptions are also not infrequent. 

Color. — The color of the feces in disease may vary a great deal. 
When unaltered bile is present, the stools may assume a golden- 
yellow, a greenish-yellow, or even a green color. In cases of biliary 
obstruction or suppression, on the other hand, they become pasty 
and have a grayish or even a white color. This, however, is not so 
much due to the absence of coloring-matter derived from the bile, as 
to an insufficient absorption of fats, as was shown by Strumpell, who 
succeeded in obtaining stools of a light-brown color after feeding 
patients affected with catarrhal jaundice upon a diet containing 
minimal amounts of fat. Such acholic or colorless stools, as it would 
be better to say, are not only found associated with biliary obstruc- 
tion, however, but may also occur when the ducts are patent. They 
have thus been observed in various cases of leukaemia, carcinoma of 
the stomach or intestine, in simple infantile enteritis, chronic nephri- 
tis, chlorosis, scarlatina, tubercular enteritis, and especially frequently 
in debilitated consumptives and in cases of chronic tubercular peri- 
tonitis in children. In some of these conditions, as in tuberculosis 
of the intestines and of the peritoneum, the lack of color is probably 
due to a diminished absorption of fats. In others, however, this ex- 
planation does not hold good, as abnormally large amounts of fat are 
not necessarily present. In such cases the lack of color is probably 
referable to the formation of colorless decomposition -products of bili- 
rubin, such as the leuko-urobilin of Nencki, but nothing definite is 
as yet known of the conditions which favor the formation of these 
products. In this connection it may be interesting to note that in 
those cases in which the biliary ducts are patent the color of the 
stools may vary not only from day to day, but even within the 
twenty-four hours. A neurasthenic patient occurring in my practice 
thus passed an acholic stool almost every morning and usually colored 
feces in the afternoon, for a period of several weeks. 

Generally speaking, the color of the stools becomes lighter the 
larger the number of movements, and vice versa. In Asiatic cholera 
and dysentery they may thus be colorless, while in severe constipation 
the scybalous masses are almost black. 

If blood is present, the stools may present a scarlet-red, a dirty 
brownish-red, a coffee, or even a perfectly black color. Adherent 



PATHOLOGY OF THE FECES. 209 

blood, usually bright red in color and found on scybalous masses, is 
probably always derived from the rectum or anus, while a change in 
color, indicating an earlier date of the bleeding, usually points to the 
colon. 

An intimate admixture of blood to the stool, the color being at the 
same time altered, so as to vary from a brownish-red to black (owing 
to the presence of sulphide of iron), is indicative of hemorrhage into 
the stomach or the small intestine. The darker the color of the 
blood the more remote from the anus will be, as a rule, the seat of 
the hemorrhage. Black or coffee -colored stools are thus observed in 
cases of ulcer of the stomach or of the duodenum, in melsena neona- 
torum, and similar conditions. 

When profuse intestinal hemorrhages take place, however, as in 
some cases of typhoid fever and melama, and particularly Avhen 
diarrhoea exists at the same time, the blood which appears in the 
stools may be changed but very little or not at all. 

While, as a rule, simple inspection or a microscopic examination 
of the feces will determine whether or not blood is present, it may 
at times be necessary to resort to more delicate tests, as the hemor- 
rhage may have been so slight as to escape detection with the naked 
eye, or so far removed from the anus that blood shadows, even, can- 
not be found with the microscope. Hemorrhages of such trivial extent 
have been reported by Hasslin as occurring quite frequently in cases 
of chlorosis. This statement, however, I have not been able to con- 
firm. If an investigation in this direction is to be made, the method 
of Midler and Weber (see p. 183), or that of Korczynski and 
Jaworski should be employed. 

Korczynski and Jaworski's Test. — A small amount of the fecal 
material is treated with a pinch of potassium chlorate and a drop of 
concentrated hydrochloric acid. The mixture is carefully heated 
until it has become decolorized, more hydrochloric acid being added 
if necessary. The chlorine is then driven off, when one or two drops 
of a dilute solution of potassium ferrocyanide are added. In the 
presence of blood-coloring matter a distinct blue color is obtained, 
owing to the formation of Prussian blue. 

An admixture of pus in notable amounts also gives rise to a 
characteristic color, as is seen in cases of dysentery, syphilitic and 
carcinomatous ulceration of the colon and rectum, following the per- 
foration of a parametritic or periproctitis abscess into the rectum, etc. 

Carter and MacMunn have recently pointed out that at times a 
chromogen may be present in the feces, which on exposure to the 
air is transformed into a red pigment, simulating blood coloring 
matter. They report three cases in which this was observed. Mac- 
Munn expresses the opinion that the substance in question is closely 
related to stercobilin. The stools showed streaks of red upon the 
14 



210 THE FECES. 

surface, and after further exposure and repeated agitation turned a 
pronounced blood-red throughout. 

Green stools are observed especially in infants, and may be refer- 
able to two different causes, being dependent on the one hand upon 
the presence of a bacillus, described by Le Sage, which produces a 
green coloring-matter, while on the other it may be referable to 
biliverclin. When green stools occur frequently this condition is 
associated with the clinical symptoms of a severe cholera infantum. 
Such stools have also been noted in dysentery, referable to an infec- 
tion with the bacillus pyocyaneus. 

Quite characteristic also are the ipecacuanha stools, which closely 
resemble the so-called acholic stools. The green color produced by 
calomel, the yellow by santonin, rheum, and senna, the black by iron, 
manganese, and bismuth, have already been mentioned (see p. 193). 

Macroscopic Constituents. 

Alimentary Constituents. — After having thus considered the 
number of stools, their consistence, reaction, odor, and color, it is 
necessary to look for gross admixtures, and especially for the presence 
of undigested food-material, such as pieces of meat, flakes of casein, — 
this especially in the stools of children, — and fragments of amyla- 
ceous food. The occurrence of such a condition, constituting what 
was formerly known as Uentery, is always indicative of disturbed 
intestinal or gastric digestion, or both. It is, hence, observed in 
cases of chronic intestinal catarrh, febrile dyspepsia, following the 
use of cathartics, etc. 

Occasionally also, a condition of affairs is seen in which almost 
unaltered food in large amounts is found in the feces, owing to a 
direct communication between the stomach and the colon, as in cases 
of perforating ulcer or carcinoma of the stomach. 

When fat is present in abnormally large amounts it can usually 
be recognized with the naked eye. To this condition the term 
steatorrhea has been applied. In typical cases the fat is seen in the 
form of whitish or grayish masses, varying in size from that of a 
pea to that of a walnut, which are more or less intimately mixed with 
the fecal material, and may at first sight be mistaken for flakes of 
casein. From these, it may be distinguished, however, by its chem- 
ical reactions and its peculiarly glistening appearance. In other 
cases stools may be seen in which the fecal column is covered, to a 
greater or less extent, with a grayish, dense, asbestos-like substance, 
while the core itself presents the usual color. Nothnagel states that 
this appearance is referable to the congealment of the fat, when it is 
exposed to a lower temperature than that of the body. I have re- 
peatedly observed this appearance, however, in stools which had just 



PATHOLOGY OF THE FECES. 211 

been voided and were still warm. The passage of liquid oil in the 
absence of fecal material has also been recorded, but it seems doubt- 
ful that the oil in such cases entered the body by the mouth. Fol- 
lowing the use of oil enemata such stools are, of course, seen. 

The elimination of abnormally large quantities of fat may be due 
to the ingestion of correspondingly large amounts. More frequently, 
however, it is referable to distinct pathologic conditions. A stea- 
torrhea will thus naturally occur when an insufficient supply of bile 
is poured into the small intestine, and is hence constantly observed 
in cases of biliary obstruction. In these cases, however, the micro- 
scope is usually necessary to demonstrate the presence of the abnor- 
mally large quantities of fat. True steatorrhea, on the other hand, 
viz,|the presence of fat recognizable with the naked eye, is more 
commonly met with in diseases affecting the resorptive power of the 
small intestine, such as extensive atrophy or amyloid degeneration 
of the intestinal mucosa, tubercular ulceration, etc., or in diseases 
involving the integrity of the lymphatic glands and vessels of the 
mesentery, as in chronic tubercular peritonitis, caseous degeneration 
of the mesenteric glands, etc. In simple catarrhal conditions, how- 
ever, steatorrhea may also occur, and not only in infants, but, ac- 
cording to my experience, also in adults. The question whether or 
not steatorrhea is constantly observed in cases of pancreatic disease, 
as some observers have claimed, may now be answered in the nega- 
tive, although it must be admitted that the two conditions are very 
frequently associated. Le Nobel, who has recently investigated this 
subject, arrived at the conclusion that the steatorrhea in itself is of 
little practical importance, but that its association with the absence 
of products of putrefaction from the stools, the absence of the salts 
of the fatty acids, and the presence of maltose in the urine, may 
possibly be regarded as indicating the existence of pancreatic disease. 

Mucus and Mucous Cylinders. — As long as mucus occurs in 
small particles only, adherent to otherwise normal feces, it is of no 
pathologic significance. Larger amounts are almost always indica- 
tive of a catarrhal condition of the colon or rectum, no matter 
whether the stool is otherwise normal, or whether diarrhea exists at 
the time. Peculiar formations are occasionally seen, viz, so-called 
mucous cylinders, which are passed in large or small fragments in a 
condition which has been described by Nothnagel as enteritis mem- 
branosa, or collect mucosa. Such masses, which at times measure a 
foot or more in length, are ribbon- or net-shaped, and are frequently 
passed in the absence of fecal matter, with severe tenesmus. They 
closely resemble Curschmann's spirals, but lack the central thread 
and the Charcot- Leyden crystals. They are probably indicative of 
chronic constipation, associated with catarrh of the colon. Not to 
be confounded with this condition is the passage of masses of mucus, 



212 THE FECES. 

which do not present the cylindrical form, but which also may be 
passed with a great deal of tenesmus and in the absence of fecal mat- 
ter ; this is very commonly seen in cases of nephroptosis, associated 
with gastroptosis and enteroptosis. These formations are in all 
probability also referable to a catarrhal condition of the colon. In 
cholera Asiatica particles of mucus are seen which resemble grains of 
rice ; their presence was formerly regarded as characteristic of the 
disease, but they are now known to occur in ordinary catarrhal con- 
ditions also. 

Biliary and Intestinal Concretions. — Most important from a 
diagnostic standpoint is the examination of the feces for the presence 
of biliary concretions, which should never be neglected in cases of 
colicky abdominal pain of doubtful origin, whether associated with 
jaundice or not. 

When searching for gallstones the feces should be stirred with 
water and passed through a fine sieve. Biliary concretions may then 
be found as small, crumbling masses, or as hard stones presenting an 
irregular contour or the smooth, characteristic facets. In size they 
may vary from that of a millet-seed to that of a pigeon's egg ; large 
stones are but rarely passed by the bowel unless perforation has 
occurred into the intestines and usually into the colon. 

Some calculi consist almost entirely of cholesterin, while others 
are composed essentially of inspissated bile, and still others of cal- 
careous salts. The former are the most common, and are readily 
recognized by their softness and color, which may be white, grayish, 
bluish, or greenish. Their specific gravity is lower than that of 
water. Very frequently they contain a nucleus, composed of earthy 
sulphates or phosphates. An analysis which I made of a large stone 
of this kind, weighing 10.548 grammes, gave the following results : 

Cholesterin 72.59 per cent. 

Mineral salts 0.247 " 

Fats 5.09 " 

Biliary pigments 13.93 " 

Organic matter . . . . . . 7.27 " 

Calculi, which consist largely of biliary pigments, are brown in 
color. They are hard, and heavier than water. Frequently they 
contain traces of copper and zinc (Fig. 42). 

Calculi composed of calcareous salts generally present an irregular, 
roughened contour. 

Within recent years Welch has drawn attention to the not infre- 
quent presence of pure colonies of the bacillus coli communis in gall- 
stones, apparently forming their nucleus. Typhoid bacilli also, have 
since been observed in their interior, and it appears likely that the 
formation of gallstones is primarily referable to an invasion of the 
gall-bladder by such micro-organisms. 



PATHOLOGY OF THE FECES. 213 

Analysis of Gallstones. — The stone is finely powdered and dried at 
a temperature of 100° C. It is then extracted with boiling water 
and the washings concentrated upon a water-bath to about 100 c.c. 
One portion of this amount is evaporated to dryness, and the soluble 
residue, as well as the mineral ash, determined after desiccation at a 
temperature of 105° C. The other portion is likewise evaporated to 

Fig. 42. 




Gallstones. 
a, cholesterin ; b, pigment-stones. 

dryness and extracted with alcohol containing a small amount of 
ether, sodium glycocholate being thus obtained. After treatment 
with hot water, as described, the substance is successively extracted 
with alcohol and ether. In the alcoholic extract fats and a small 
amount of cholesterin will be found. The greater portion of this is 
in the ethereal extract. The residue, which is insoluble in hot water, 
alcohol, and ether, is treated with a moderately strong solution of 
hydrochloric acid, the earthy phosphates and oxides being thus ob- 
tained united to pigments. The bilirubin is removed by extracting 
with boiling chloroform. The pigments which are not dissolved in 
this manner are biliprasin, bilihumin, etc. 

Intestinal concretions (enteroliths) are rare and usually come from 
the appendix. At times they contain some foreign body, such as a 
grape-seed, as a nucleus, upon which calcium and magnesium salts 
have become deposited. 

Fecal calculi or coproliths are likewise only rarely seen. They 
represent inspissated fecal material which has become impregnated 
with lime and magnesium salts. More commonly they are found at 
the post-mortem table in the caecum, in the haustra of the colon, and 
in the rectum. 

Microscopic Examination. 

Technique. — In hospital work the stool should be passed into a 
well-warmed bed-pan and examined at once. This is particularly 
important in the search for amoebae. In private practice patients 
should be instructed to send their stools to the physician, as soon as 
possible, when suspicions-looking particles should be placed upon the 
warm-stage or examined upon a, well-wanned slide. A very convenient 
form of warm-stage, which may be obtained from instrument makers 



214 THE FECES. 

at low cost, is composed of brass and made to be held in position on 
the stage of the microscope by spring clips. It is about 8 cm. long 
and 3 cm. broad, and has cemented to a recessed bottom an ordinary 
glass slip ; an opening of 1.35 cm. is in the centre of the stage. To 
one of the long sides of the brass stage is fitted a projecting stem, 
about 10 cm. long, to which the heat of a spirit-lamp is applied. 

For ordinary purposes it is well to place the stool, if watery, in a 
conical glass and to cover it with a layer of ether, so as to diminish 
the disagreeable odor. If mushy or firm, it should be spread out 
upon a plate and covered with a layer of turpentine, or a 5-per-cent. 
solution of carbolic acid or thymol. 

Remnants of Food. — It has already been pointed out that various 
microscopic remnants of food are observed in normal feces. In path- 
ologic conditions it is necessary to determine whether or not such 
remnants are present in abnormal amount, presupposing, of course, 
that excessive quantities of food have not been ingested. It is often 
possible to draw definite conclusions as to the state of intestinal di- 
gestion from the excess of one form of non-digested material over 
another. The presence of large quantities of undigested starch gener- 
ally indicates a serious catarrhal condition of the small intestine 
and it may, indeed, be said that the occurrence of more than mere 
traces of this material should always be regarded with suspicion. 
An increase in the number of muscle-fibres will likewise be observed 
under such conditions. 

The so-called acholic stools are usually very rich in fat, and par- 
ticularly so in cases of biliary obstruction, associated with jaundice. 
At other times, however, the lack of color, as has been mentioned 
above, is not referable to the secretion of an insufficient amount of bile, 
but to the presence of colorless decomposition products of bilirubin, 
such as the leuko-urobilin of Nencki. In these cases abnormally large 
quantities of fat are not always present. The conclusion that a stool 
contains excessive amounts of fat because it is apparently acholic is 
hence not justifiable unless a microscopic examination has been made. 

Leiner's Test for Casein. — Casein is most conveniently demon- 
strated with Leiner's method. To this end a small amount of fecal 
matter is spread on a slide and dried in the air. It is then fixed by 
heat, — passing the specimen through the flame of a Bunsen burner, 
three or four times is sufficient, — and stained with a mixture of equal 
parts of an 0.7 5-per-cent. solution of acid fuchsin and methyl-green 
in 50-per-cent. alcohol, the mixture being diluted ten times with 
water. After fifteen minutes the preparations are placed in distilled 
water and allowed to remain for one hour or longer. Casein and 
paracasein are thus stained a pale blue or violet, while the pseudo-nu- 
cleinic bodies are practically all colored a light green, or more rarely 
a yellowish-green. 



PATHOLOGY OF THE FECES. 215 

Epithelium. — Epithelial cells, when present in large numbers, 
always indicate an inflammatory condition of some portion of the 
intestinal tract. 

Cylindrical epithelial cells are found in abundance in all inflam- 
matory conditions affecting the intestinal mucosa. They are almost 
exclusively seen imbedded in mucus, and it is interesting to note that 
the cloudy appearance of the mucus is referable to the presence of 
these elements and not to leucocytes, as is the case in the sputum. 
When bile-stained specimens are met with the conclusion is justifi- 
able that the small intestine is involved. Degenerative forms are 
mostly seen ; well-preserved cylindrical or goblet cells may, however, 
also be found, and are, according to my experience, very much more 
common than is generally supposed. 

Epithelioid cells may be found in carcinoma of the rectum. 

Red Blood- corpuscles. — Unaltered red blood-corpuscles, accord- 
ing to Nothnagel, are but rarely observed in the feces, no matter 
how intensely red they may be colored, providing that an ulcerative 
process affecting the colon or the rectum can be excluded ; in that 
case, as in the severer forms of dysentery, large numbers may be ob- 
served. If the hemorrhage has occurred higher up in the intestine, 
large and small masses of a brownish-red color are seen, which con- 
sist of hsematoidin. They are mostly amorphous, but in some speci- 
mens the characteristic rhombic crystals may be observed. In general 
it may be said that the higher the seat of the hemorrhage the darker 
will be the color of the pigment, and the less the chances of finding 
well-defined red corpuscles. In such cases recourse must be had to 
the hsemin (p. 40), or the iron test of Korczynski and Jaworski 
(p. 209). 

Mucus. — Small hyaline particles of mucus, visible only with the 
microscope, are not infrequently met with under pathologic condi- 
tions, and are of distinct diagnostic significance. When bile-stained 
their presence is always indicative of disease of the small intestine 
proper, while colorless particles point to a catarrhal condition of the 
upper portion of the large intestine or the lower portion of the small 
intestine. Beginners should be careful not to mistake apparently 
hyaline particles of vegetable residue for mucus. Mucus never yields 
a blue color when treated with iodine, or iodine and sulphuric acid, 
and examination with a higher power will show the entire absence ot^ 
any definite structure. Both forms, viz, colorless and colored par- 
ticles, are found intimately mixed with the feces, and may be very 
abundant. In addition to these forms Nothnagel has described the 
occasional occurrence of large numbers of roundish or irregular, very 
pale hyaline or opaque formations, which are devoid of all structure. 
Some specimens are homogeneous, while others present a distinct 
rimous appearance. They have thus tar only been found in liquid 



2L6 THE FECES. 

stools, and are apparently of no diagnostic significance. To judge 
from their optic behavior they probably consist of mucus. 

Leucocytes. — The presence of a large number of leucocytes usu- 
ally indicates a severe catarrhal, if not an ulcerative condition of the 
intestines, the number of leucocytes or pus corpuscles standing in a 
direct relation to the intensity of the inflammatory process. Pure 
pus in large amounts is observed especially in dysentery, and in cases 
in which accumulations of pus have perforated iuto the gut from ad- 
jacent organs or cavities. 

Crystals. — The crystals which may occur in the feces have al- 
ready been briefly considered (p. 196). Of these the so-called 
Charcot-Leyden crystals deserve more detailed consideration. 
While occurring at times in normal stools, as also in those of 
typhoid fever, dysentery, and phthisis, such observations are rare. 
They appear to be quite constantly present, on the other hand, in 
cases of anchylostomiasis and auguilluliasis. They are also fre- 
quently associated with ascaris lumbricoides, oxyuris, taenia solium 
and saginata. In cases of trichocephalus they are but rarely seen, 
while they are always absent in the case of taenia nana. These 
observations, made by Leichtenstern, are very important, and, 
according to the same observer, the occurrence of Charcot-Leyden 
crystals should always excite suspicion as to the existence of helmin- 
thiasis and lead to a careful examination of the feces for parasites 
or their ova. Their persistence in the feces after the evacuation of 
what would appear to be a complete taenia should be regarded as in- 
dicating the non-removal of the head. In a case of amoebic colitis, 
occurring in the practice of Dr. Lewis, of Baltimore, these crystals 
were also observed in fairly large numbers. 

Animal Parasites. 
I. — Protozoa : 

Ehizopoda, 
M on era. 

Amcebina, Amoeba coli. 
Flagellata s. mastigophora, 
Monadina, 

Cenomonadina, Cercomonas. 
Isomastigoda, ■ 

Tetramitina, Trichomonas. 
Polymastigina, Megastoma entericum. 
Infusoria ciliata s. vera, 

Holotricha, Balantidium coli. 
Gregarina s. sporozoa, 
Coccidia. 
II. — Vermes : 

Platodes, 

Cestodes, 

Taenia saginata. 
Taenia solium. 
Taenia nana. 
Taenia diminuta. 



PATHOLOGY OF THE FECES. 217 

Tsenia cucumerina. 
Bothriocephalus latus. 
Krabbea grandis. 
Trematodes, 

Distoma liepaticum. 
Distoma lanceolatum. 
Distoma Buskii. 
Distoma sibiricum. 
Distoma spatulatum. 
Distoma conjunctum. 
Distoma heterophyes. 
Amphistoma hominis. 
Distoma haematobium. 
Distoma pulmonale. 
Annelides, 

Nematodes, 
Ascarides, 

Ascaris lumbricoides. 
Ascaris inystax. 
Ascaris maritima. 
Oxyuris vermicularis. 
Strongyloides, 

Anchylostomum duodenale. 
Trichotrac helides, 

Trichocephalus hominis. 
Trichina spiralis. 
Rhabdonema strongyloides, 
Anguillula intestinalis. 
III. — Insecta : 

Piophila casei. 
Drosophila melanogastra. 
Homialomyia. 
Hyodrothoea meteorica. 
Cystoneura stabulans. 
Calliphora erythrocephala. 
Palleuria rudis. 
Lucilia csesar. 
Lucilia regina. 
Sarcophaga htematoides. 
Eristalis arbustorum. 
Ant homy ia. 

Protozoa. — The rhizopoda are essentially characterized by the fact 
that locomotion does not take place by the aid of independent organs, 
but by means of pseudopodia, viz, protoplasmic processes which the 
animal is capable of protruding from any portion of its body. Six 
orders have been described by zoologists, but only one, or possibly 
two, have thus far been found in the feces. 

Whether or not representatives of the monera occur in the feces of 
man is still an open question. If so, they are apparently of no 
pathologic significance. 

Of the amcebina, on the other hand, a most important member has 
been found, viz, the amoeba coli, Losch. 

The history of the discovery of this parasite and its relation to 
those severe forms of tropical dysentery and liver-abscess which are 
met with also in our more temperate /ones is of much interest, ami 



218 



THE FECES. 



at the same time illustrates the great importance which attaches to a 
systematic examination of the feces in all aggravated forms of diar- 
rhoea. 

In 1875 Losch discovered, in the stools of dysenteric patients, 
actively moving, cell-like bodies of a roundish, pear-shape, oval or 
irregular form. He did not regard these as the cause of the disease, 
however, but looked upon them as being only accidentally present. 
Similar bodies were observed in Hong-Kong by Normand in cases of 
colitis ; and also by v. Jaksch. Sansino found them in a case in 
Cairo, and Koch in East Indian dysentery. It is interesting to note 
that Koch was the first to suspect the existence of a definite relation 
between dysentery and these organisms. Cunningham claims to have 
frequently found amoebae in the stools of cholera patients at Calcutta, 
and Grassi in normal stools, but especially abundant in cases of 
chronic diarrhoea. Whether all these observations are correct, and 
whether the organisms observed were identical in all cases, is, of 
course, difficult to say. So much is certain, that the subject was still 



Fig. 43. 




The amoeba col 



a very unsettled one when Kartulis announced " that dysentery and 
tropical liver-abscess, associated with dysentery, are caused by the 
presence of the amoeba coli," basing his conclusion upon an examina- 
tion of 500 cases. The fact that this parasite was absent in all other 
intestinal diseases, such as typhoid fever, intestinal tuberculosis, the 
ordinary forms of diarrhoea, etc., speaks most strongly in favor of 
Kartulis' view. 

In perfect accord with these observations were those made at the 
Johns Hopkins Hospital by Osier, Lafleur, and Councilman. Osier 
was the first in this country to demonstrate the presence of the 



PATHOLOGY OF THE FECES. 219 

amoeba coli in a case of liver-abscess, both in the pus of the abscess 
and in the stools. Stengel, Musser, Dock, and others confirmed 
these observations, so that the pathogenic character of the amoeba 
coli may now be regarded as an established fact. This statement 
is based not only upon the few facts, more historical in character 
than otherwise, which have just been detailed, but rather upon the 
ensemble of collected data, among which the absence of micro- 
organisms other than the amoeba in the pus of the liver-abscesses, 
and the constant presence of the latter in such cases, rank among 
the most important. 

The size of the amoebae varies from 10 /i to 20 fi. "When at rest 
their outline is, as a rule, circular, occasionally ovoid ; but when in 
motion they present the extremely irregular contour of moving 
amoeboid bodies (Fig. 43). The protoplasm can be differentiated 
into a translucent, homogeneous ectosarc or mobile portion, and a 
granular endosarc, containing the nucleus, vacuoles, and granules. 
Within the endosarc the vacuoles constitute the most striking feat- 
ure. Sometimes the interior seems to be made up of a series of 
closely set clear vesicles of pretty uniform size. As a rule, one or 
two larger vacuoles are present, the edges of which are not infre- 
quently surrounded by fine dark granules. True contractile vesicles, 
displaying rhythmic pulsations have not been observed, although the 
vacuoles may at times be seen to undergo changes in size. In some 
the nucleus is quite distinct, while in others it may be altogether in- 
visible. 

Most distinctive are the movements of these bodies. From any 
part of the surface a rounded, hemispherical knob will project, and 
with a rapid movement the process extends and the granules in the 
interior flow toward it. In these movements the clear ectosarc 
seems to play the most important part. 

In this connection I wish to refer to the occurrence of Laveran's 
plasmodiam malarias, enclosed in red corpuscles, in the stools of cases 
of malarial colitis. In one case of chronic malarial intoxication 
with dysenteric symptoms the diagnosis was first made after an ex- 
amination of the stools for amoeba? ; these were absent, however, 
while a number of plasmodia could be demonstrated, pointing out 
the probable nature of the colitis. 

The flag el lata s. mastigophora differ from the rhizopoda in being 
provided with from one to eight flagella, which serve as organs oi' 
locomotion and possibly also for the apprehension of food-particles. 
Representatives of two orders only, viz, the monadina and Lsomasti- 
goda, have been found in the feces. Of the monadina in turn only 
one family, viz, the cenomonadina, and of the isomastigoda only two 
families, viz, the tetramitina and polymastigina, are represented. 

The cenomonadina are small, oval, frequently elongated bodies, 



220 



THE FECES. 



provided with one long flagellurn at the anterior end, at the base of 
which food vacuoles are situated. At the posterior end amoeboid 
movements may be observed, and there can be no doubt that the 
taking up of food, to some extent at least, also occurs by the aid of 
pseudopodia. To this family belongs the cercomonas of Davaine 
and Lambl. The tetramitina are small, elongated bodies, provided 
with four flagella and a lateral, undulating membrane, which was 
formerly mistaken for a posteriorly directed flagellum. The tail 
end of the organism tapers to a point. The nucleus is located at 
the base of the flagella. To this family belongs the parasite which 
was first discovered by Donne" in the vagina, and which was later also 
found in the feces and variously designated as trichomonas hominis, 
cercomonas coli hominis, etc. 

The polymastigina are small, somewhat oval bodies, provided with 
two or three flagella, situated either anteriorly or laterally — two or 
three on each side, — while at the same time two additional flagella 
issue from the posterior end, which may either be rounded off or 
taper to a point. To this family belongs the megastoma entericum 
of Grassi. ' 

Fig. 44. 




Cercomonas intestiualis. 

a, cercomonas of Davaine, after Leuckart; b, cercomonas intestinalis, after Lambl ; c, d, same, 
ordinary forms; e,f, same, well-developed forms; g, h, i, same, degeneration forms; k, I, same, 
abortive forms. 



Only three parasites belonging to the order of the flagellata have 
thus far been encountered in the human feces, viz, the cercomonas 
hominis of Davaine and Lambl, the trichomonas of Donne, and the 
megastoma entericum of Grassi. To judge from the earlier litera- 
ture upon the subject, many others have also been found, but more 



PATHOLOGY OF THE FECES. 



221 



modern investigations have shown that they are in reality identical 
with the three just mentioned. The question, whether or not these 
flagellate bodies are of pathologic importance still remains sub judice. 
They are apparently only met with in diseases associated with diar- 
rhoea, and it appears that in some cases, at least, this is directly de- 
pendent upon their presence. In others the impression is gained as 
though they merely maintained an already existing diarrhoea, refer- 
able to other causes, while in a third class of cases no relation can be 
discovered between their presence and the disease in question. 

Cercomonas of Da vain e-Lambl, syn., cercomonas hominis (Davaine); 
monas (Marchand); monas lens (Grassi); monas monomitina (Grassi). 
The adult organism (see Fig. 44) is oval or roundish in form, and 

Fig. 45. 




Trichomonas intestinalis. 
a, a', c, trichomonas of the urine, after Marchand ; b, trichomonas vaginalis, after Donne : b' 
same, after Scauzoni and Kollicker; d, trichomonas intestinalis, after Piecardi ; e, e', t", same 
amoeboid forms ; /,/', trichomonas of the urine, after Dock. 



provided anteriorly with a single long flagellum and posteriorly with 
a tail-like appendage. Its length varies from 0.005 to 0.014 mm. 
The younger forms are pear- or S-shaped, and sometimes irregular in 
outline ; the flagellum is cither absent or only rudimentary. 

Upon prolonged observation it will be seen that the adult parasite 
looses its flagellum and may protrude a protoplasmic process instead, 



while vacuolation occurs 
death. 



at the same time, indicating approaching 



222 



THE FECES. 



Trichomonas, Donne, syn., trichomonas vaginalis (Donne); tricho- 
monas hominis (Grassi) ; monocercomonas (Grassi) ; cimsenomonas 
(Grassi) ; protorycomyces coprinarius (Cunningham and Lewis) ; 
cercomonas coli hominis (May) ; trichomonas intestinalis (Leuckart 
and Roos) ; cercomonas s. bodo urinarins (Kiinstler). The parasite 
(Fig. 45) is oval or spindle-shaped and measures from 0.012 to 0.030 
mm. in length by 0.010 to 0.015 mm. in breadth. From its anterior 
pole four flagella are given off, which are almost as long as the or- 
ganism itself. From this point an undulating membrane extends 
laterally to the posterior pole, which may be rounded off or taper to 
a tail-like appendage. This membrane is best seen when the move- 
ments of the flagella have ceased, or in specimens fixed in bichloride 
of mercury solution (1 : 5,000). The nucleus is situated at the base 
of the flagella, but is usually only visible in stained specimens (methy- 
lene blue). At times the organisms may be observed to assume an 

Fig. 46. 




Megastoma entericum. 
a, b, b', c, c', c", c"', various forms of cercomonas intestinalis, after Lambl ; d, d', encysted forma 
of megastoma entericum, after Grassi and Schewiakoff ; e, megastoma entericum, adult form. 

amoeboid form ; the movements of the flagella have then ceased, and 
pseudopodia-like processes are protruded. The parasite is identical 
with the trichomonas which has been found in the vagina and in 
the urine. 



PATHOLOGY OF THE FECES. 223 

Megastoma entericum, Grassi, syn., cercomonas intestinalis (Lambl); 
megastoma intestinale (Biitschli); lamblia intestinalis (Blanchard) ; 
dimorphus muris (Grassi). The parasite (Fig. 46) is pear-shaped, 
and measures from 0.01 to 0.021 mm. in length, by 0.0075 to 0.05 
mm. in breadth. In its anterior portion a more or less well-marked 
depression can be made out, which constitutes the peristome or 
mouth opening of the organism. It is provided with eight flagella, 
grouped in pairs. The first pair originates on the sides of the 
peristome and is directed backward. The second and third pair are 
situated somewhat posteriorly and are likewise directed backward, 
while the fourth pair issues from the tapering tail-end of the body. 
In fresh specimens the eighth flagella can usually not be made out, 
as the third and fourth pair are frequently agglutinated. The best 
results are obtained when the organism has been killed with bi- 
chloride solution. The individual flagella vary from 0.009 to 0.014 
mm. in length. In the anterior portion of the peristome two round, 
hyaline bodies can be recognized, which represent nuclei. Vacuoles 
are absent, and nutrition occurs through osmosis, the parasite ad- 
hering to epithelial cells by its peristome. When treated with fix- 
ing solutions the chitinous envelope can be readily recognized. In 
the encysted form the organism is oval and measures from 0.007 to 
0.1 mm. in diameter. 

Grassi observed the organism in mice, rats, cats, dogs, rabbits, and 
sheep. 

Balantidium coli (Malmsten), syn., paramcecium coli. The organ- 
ism is egg-shaped, 0.1 mm. long, and covered entirely with fine cilia, 
which are grouped most densely about the mouth, while the anus is 
surrounded by only a few. In its interior are found a nucleus, two 
contractile vesicles, and frequently fat-droplets, particles of starch, 
etc. The parasite is most common in Sweden, but has also been 
observed in Germany, Cochin-China, Italy, and the United States. 
Infection occurs through the dejecta of swine. 

The fourth class of protozoa, viz, the Gregarina or sporozoa, is 
also said to be represented in the human feces. The coccidia and 
psorosperms belong to this order. They are small, oval bodies, 
measuring about 0.022 mm. in length, and contain in their interior 
a large number of small nuclei, arranged in groups. They are en- 
tirely devoid of organs of locomotion, and obtain their nutriment 
by endosmosis. Reproduction occurs in a common capsule, which 
bursts at a certain time and sends forth a whole generation of fully 
developed organisms. In human pathology they have become of 
interest in so far as certain observers have ascribed to them a rdle in 
the etiology of neoplasms. A disease of the liver analogous to the 
psorospcrmiasis of rabbits has also been described in man, and para- 
sites belonging to the same order have recently been observed in the 



224 



THE FECES. 



skin. The two cases reported by Gilchrist and Rixford ended fatally, 
and post-mortem examination reyealed extensive infection of the 
spleen, adrenal glands, testes, lymphatic glands, and kings. 



Fig. 41 






Taenia saginata. 
a, natural size ; b, head much enlarged ; c, ova much enlarged. 



Vermes. — The class vermes has interested physicians since time 
immemorial, and is referred to in the writings of Hippocrates and 
others, special mention being made of the ascarides, called lumbrices, 
and the platodes, called lati. Speaking of the former, Lncas Tozzi, 
in 1686, says : "They find their way into the heart and its pericar- 



PATHOLOGY OF THE FECES. 225 

dium, into the brain, the lungs, the veins, and gall-bladder, where 
they are difficult to 'catch/ " The same author, speaking of their 
effects upon the body, enumerates the following conditions as caused 
by their presence : epilepsy, vertigo, sopors, delirium, convulsions, 
headache, syncope, palpitations, feeling of anxiety, cough, vomiting, 
nausea, diarrhoea, hiccough, prickling, borborygmi, erosions, tabes, 
acute and chronic fevers, and innumerable other maladies. 

It was even then deemed very important to make a diagnosis 
before the administration of an anthelmintic — a point which is well 
to bear in mind at the present day, and the eggs, segments, or para- 
sites themselves should be sought for in every suspected case, before 
treatment is begun. 

Tcenia saginata, Goeze, syn., t. mediocanellata (Kuchenmeister) ; 
t. incruris (Huber) ; t. dentata (Nicola). This parasite (Fig. 47) is 
the most common tapeworm both in Europe and North America. 
Infection occurs through the ingestion of measly beef. Its length 
varies from 4 to 8 m. The head, which is devoid of a rostellum, is 
surrounded by four pigmented suckers, each of which is encircled by 
a dark line. The individual segments are quite thick and opaque, 
and diminish in length as the head is approached, the largest measur- 
ing from 2 to 3 cm. They are each provided with a very much 
branched uterus, which opens laterally, the primary branches num- 
bering about twenty on each side. The ova are elliptical in form, 
of a brown color, and usually enclosed in a distinct vitelline mem- 
brane. Upon careful observation a double contour with delicate 
radiating striae can be discerned. In the interior the embryos are 
seen imbedded in a brown, granular material. 

Thus far the cysticercus of taenia saginata has not been observed 
in the human being. 

Fig. 48. 




X 4."> 



Tcenia solium, Rudolph!. This parasite (Fig. 48) is far less com- 
mon in this country than the taenia saginata, and may indeed be re- 
arded as a curiosity. In Germany, also, it is only rarely met with 
\v, while formerly it was the most common tapeworm in that 
15 



no 



226 THE FECES. 

country. This change is undoubtedly owing to the fact that raw pork 
is now eaten less frequently. In Asia and Africa it is more com- 
mon. Taenia solium is usually much shorter than taenia saginata, 
rarely exceeding 3.5 m. in length. Most characteristic is the head, 
which is provided with four pigmented suckers and a rostellum, fur- 
nished with from twenty-four to twenty-six hooklets, arranged in a 
double row. The mature segments measure from 1.0 to 1.5 cm. in 
length by 6 to 7 mm. in breadth, and contain a uterus which has 
only five to seven branches, thus differing greatly from that of taenia 
saginata. The ova are round, of a brownish color, and surrounded 
with a thick, radially striated membrane ; in their interior the hook- 
lets of the embryos can usually be made out. 

At times, though rarely, an autoinfection with the proglottides of 
taenia solium has been observed in the human being. Under such 
conditions the embryos of the worm are set free in the stomach, and 
may then migrate into various parts of the body, where they become 
encysted, constituting the so-called cysticercus eellulosce stage in the 
development of the parasite. Most commonly the cysticerci are 
found in the skin ; they have, however, also been observed in the 
heart, lymphatic glands, liver, bones, tongue, spinal canal, the brain, 
and the eyes. I have had occasion to observe a case of this kind at 
the Johns Hopkins Hospital (reported by Osier). The patient, a 
laboring man, had never worked as a butcher or a cook, and never 
had a tapeworm. The cysticercus nodules, which were situated be- 
tween the skin and the fascia, were very numerous, seventy-five be- 
ing counted on one day. One of these nodules was removed for ex- 
amination and shown to be referable to the cysticercus of taenia 
solium. The only subjective complaints in this case were pains and 
stiffness in the arms and legs. The individual cysticercus was ellip- 
tical or roundish in form, measuring from 1 to 10 mm. in diameter. 
In its interior the characteristic hooklets were seen. 

Tcenia nana, v. Siebold, syn., hymenolepsis (Weinland). This 
parasite (Fig. 49) has not been observed in America, but seems to 
be the most common tapeworm in Italy and Egypt, being found 
especially in young people, and often causing severe nervous symp- 
toms, such as convulsions, loss of consciousness, and even melan- 
cholia. It is only 8 to 25 mm. long and 0.5 mm. broad. The 
head is ball-shaped and provided with four suckers and a rostellum, 
bearing twenty-four to twenty-eight hooklets arranged in a single 
row along its anterior edge. The individual segments are of a yel- 
lowish color and about four times as broad as long. The uterus is 
oblong and contains numerous ova, which are colorless, oval and 
surrounded by a distinct non-striated membrane. They measure 
from 0.039 to 0.060 mm. in size. In their interior the embryonic 
worm, provided with five or six hooklets, may be distinguished. 



PATHOLOGY OF THE FECES. 



227 



The number with which this parasite at times infests the digestive 
tract is most astonishing, 5,000 and even more having been counted 
at various times. The cysticercus stage occurs in snails, which are 
frequently eaten raw in Egypt and Italy. 

Fig. 49. 






Taenia nana. Head, with rostellum drawn in ; proglottis; egg. (v. Jaksch. ) 



Tcenia diminuta, Rudolphi, syn., taenia flavapunctata (Weinland) ; 
taenia minima (Grassi); taenia varerina (Parona) ; taenia leptocephala 
(Creplin). Taenia diminuta was first described in man by Leidy, 
Grassi, and Parona. It measures 20 to 60 mm. in length, and is 
armed with two suckers, but is without a rostellum. The ova re- 
semble those of taenia solium. The cysticercus occurs in certain 
caterpillars and cocoons. In man it has only been found in six in- 
stances. 

Tcenia cucumerina, Bloch, syn., taenia canina (Linne) ; taenia ellip- 
tica (Batsch) (Fig. 50). The parasite is almost exclusively found 
in children, the infection occurring through dogs and cats. Its 
length varies from 10 to 40 mm. The head is provided with about 
sixty hooklets, surrounding a rostellum in irregular rows. When 
this is visible it appears as a club-shaped protuberance. The ripe 
segments have a reddish color, and are very much longer than 
broad. The ova contain embryos already armed with hooklets. 
The cysticercus occurs in fleas. 

Bothrioccphalus lotus, Bremser, syn., taenia lata (Linne) ; diboth- 
rium latum (Rudolphi) (Figs. 51 and 52). This worm is 5 to 
9 m. long. Its head is shaped like a bean, and upon its flat sur- 
faces two distinct grooves can be discerned, which probably act as 
suckers. The ripe segments arc almost square in form, with the 
genital apparatus opening in the median line. The uterus presents 
four to six convolutions on each side, which become especially dis- 
tinct when the segments are placed in water or exposed to the air. 



228 



THE FECES. 



A rosette-like appearance is then obtained, which is quite charac- 
teristic. The eggs are oval, 0.07 mm. long and 0.045 mm. broad • 
they are enclosed in a brown envelope, at the anterior end of which 
a little lid can be recognized. Their contents consist of protoplasmic 
spherules, all of about the same size, which are lighter in color in 



Fig. 50. 



Fig. 51, 




Ta?nia cucumerina. Head ; proglottis ; magnified. 
(v. Jaksch.) 



Fig. 52. 





Bothriocephalus latus. Head. 



Bothriocephalic latus. 



the centre than at the periphery. The larvae have been found in 
various fishes, such as the perch, trout, and burbot, but most fre- 
quently in the pike. It is thus readily understood why the parasite 
is most common in lake regions, as in Switzerland, northern Russia, 



PATHOLOGY OF THE FECES. 



229 



southern Scandinavia, and northern Italy. Outside of Europe it is 
most common in Japan. In the United States it has only been found 
in a few imported cases. From a pathologic standpoint it is of much 
interest, as it appears to stand in a generic relation to certain forms 
of severe anaemia. 

Krabbea grandis, Blanchard. This parasite has been observed in 
only one instance — in eastern Asia. It is said to resemble certain 
bothriocephali which are found in seals. 

Trematodes. — The various forms of distoma which belong to this 
order are essentially hepatic parasites, and rarely occur in the feces. 



Fig. 53. 



Fig. 54. 






Distoma hepaticum. (Leuckart. ) 



Distoma lanceolatum (X 8) and eggs. (v. Jaksch. ) 



Distoma hepaticum, Abildgaard, syn., fasciola hepatica (Linne) 
(Fig. 53). This, the most common liver-fluke, is 28 mm. long and 
12 mm. broad ; it is formed like a leaf. The head is provided with 
a sucker, and a second sucker may be found at its ventral surface. 
Between the two the genital opening is located, leading into a skein- 
shaped uterus. The edges are oval, measuring 0.13 mm. in length 
and 0.08 mm. in breadth, the anterior end being provided with a lid j 
their color is brown. In the United States the organism is practi- 
cally unknown, while in Germany it is most common in sheep. In 
the human being it is rare in both countries. Infection occurs 
through a small snail, the Linnaeus minutus, which is found, in Ger- 
many especially, upon watercress. 

Distoma lanceolatum, Mehlis, has only been found in five eases, 
all of which occurred in Germany (Fig. 54). It is much smaller 
than distoma hepaticum, measuring 8 to 9 mm. in length, by 2 to 
3.3 mm. in breadth. It is lancet-shaped, tapering toward the head 
end, but otherwise closely resembles the above parasite. The ova 
are 0.04 mm. long, 0.03 mm. broad, and contain fully developed 
embryos. In the ruminants the organism is quite common. 



230 



THE FECES. 



Distoma Bushii, Lancester, syn., distoma rhatonisii (Poirier) ; dis- 
toma cranum (Busk). The parasite has been observed in only three 
cases — in China. It is much larger than the common liver-fluke. 
Infection probably occurs through certain fishes and oysters. 

Distoma sibiricum, Winigradoff, syn., distoma felineum (Rivolta). 
This parasite was found in Tomsk, by "Winigradoff, in eight autopsies 
out of 124. Its length may reach 13 mm. The ova are 0.026 to 
0.038 mm. long and 0.010 to 0.022 mm. broad. The intestine is 

Fig. 55. 




Ascaris lurnbricoides. (v. Jaksch.) 

a, worm, half natural size; b, head, slightly magnified; c, eggs. (Eye-piece I., objective 8 A, 

Reichert. ) 



simple and extends to the posterior extremity of the body. Its sur- 
face is smooth. 

Distoma spatulatum, Leuckart, syn., distoma endemicum (Balz) ; 
distoma japonicum (Blanchard) ; distoma sinense (Cobbold). The 
habitat of the organism is in cats. In the human being it has only 
been observed in Japan, where it appears to be quite common in 
certain localities. It is about 11.75 mm. long and 2 to 2.75 mm. 
broad. The living parasite is of a reddish color and translucent, so 
that it is possible to distinguish all its interior organs. The ova 
measure 0.028 to 0.030 mm. in length by 0.016 to 0.017 mm. in 
breadth, and are enclosed in a colorless envelope. 



PATHOLOGY OF THE FECES. 



231 



Distoma eonjunetum, Cobbold, distoma heterophyes, v. Siebold, and 
am/phistomum hominis, Lewis and McConell, are other parasites which 
have been observed in a few isolated cases, but are as yet of no spe- 
cial interest. The last named appears to be common in elephants. 

Distoma haematobium and distoma pulmonale are described in the 
sections on Blood and Sputum, respectively. 

The annelides are very common intestinal parasites, and of these 
especially the nematodes. 

Asearis lumbrieoides (Linne) (Fig. 55) is the cylindrically shaped 
worm so commonly seen in children and in the insane. The head 
consists of three projections or lips, which are provided with suckers 
and fine teeth. The male measures about 215 mm., the female 



Fig. 56. 



Fig. 57. 




Asearis rnystax. (v. Jaksch. ) 
a, male ; b, female ; c, head ; d, egg. 




Oxyuris vermicularis. (v. Jaksch. 
a, head ; b, male ; c, female ; d, eggs. 



about 400 mm. in length. The tail-end of the male is rolled 
up on its ventral surface like a hook and provided with papillae. 
The genital aperture of the female is situated directly behind the 
anterior third of the body. The eggs are yellowish-brown in 
color, almost round, and measure 0.0() mm. by 0.07 mm. in size ; 
they are surrounded by an irregular albuminous envelope, which is 
covered by a tough shell ; the contents are coarsely granular. 

Asearis lumbrieoides is found in all countries, and also infests 
the pig and the ox. Its presence may occasion very severe nervous 
symptoms, but fortunately this is but rarely the case. 

Asearis rnystax, Zcder, syn. } asearis marginata (Rudolph!) : asearis 
alata (Bellingham) (Fig. 56) is smaller and thinner than asearis 
lumbrieoides, but otherwise very similar. The head is pointed and 



232 



THE FECES. 



provided with wing-like projections, which constitute the main point 
of difference between the two. The male measures 45 to 60 mm. in 
length, the female 110 to 120 mm. Its ova are round, larger than 
those of ascaris lumbricoides, and enclosed in a membrane which is 
covered with numerous small depressions. The worm is very com- 
mon in dogs and cats, but very rare in man. 

Ascaris maritima, Leuckart, also belongs to this class. It has 
only been observed in one case — in Greenland. 

Oxyuris vermicularis, Bremser, syn., ascaris vermicularis (Linne) ; 
ascaris grsecorum (Pallas) (Fig. 57). The male is 4 mm., the 
female 10 mm. long. At the head three lip-like projections with 
lateral cuticular thickenings may be seen. The tail of the male is 



Fig. 



~b a 




Anckylostomum duodenale. (v. Jaksch. ) 

a, male, natural size ; b, female, natural size ; c, male, magnified ; d, female, magnified ; e, head 
(eye-piece II., objective C, Zeiss) ; /, eggs. 

provided with six pairs of papillae, and the female with two uteri. 
The eggs are 0.05 by 0.02 to 0.03 mm. in size, and covered with a 
membrane, showing a double or triple contour ; in the interior, 
which is coarsely granular, the embryos are contained. 

The female worm lives in the caecum, but after impregnation 
travels downward to the rectum. Here it causes most annoying 
symptoms, which are especially distressing at nights, when the or- 
ganism emerges from the anus. In doubtful cases of pruritus ani 
aut vulvae an examination of the feces should be made for this para- 
site. The ova themselves do not occur in the feces. 

Anehylostomum duodenale ( Dubini ) ; anchylostoma duodenale 
(Dubini) ; strongylus quadridentatus (v. Siebold) ; dochmius anchy- 
lostomum (Molin) ; sclerastoma duodenale (Cobbold) ; strongylus 



PATHOLOGY OF THE FECES. 



233 



Fig. 59. 



duodenalis (Schneider) ; dochmius duodenalis (Leuckart) ; uncinaria 
duodenalis (Roilliet) (Fig. 58). The organism belongs to the fam- 
ily strongy hides, and is one of the most dangerous parasites met with 
in the human being. It has been found in Italy, Germany, Switz- 
erland, Belgium, Egypt, and in the West Indies (Jamaica). Within 
the last few years several cases have also been reported in the United 
States. From a pathologic standpoint the parasite is of special in- 
terest, as its presence gives rise to severe and often fatal anaemia. 
Oriesinger was the first to point out that the so-called Egyptian 
chlorosis is produced by this organism. In every case of severe 
anaemia, particularly when occurring in patients who have been 
working in mines, tunnels, and brickyards, 
the feces should be carefully examined for 
the ova of this parasite. The worm itself 
is only rarely found. Its habitat is in the 
jejunum. Infection takes place through 
contaminated drinkingwater. 

The male is 6 to 11.5 mm. long, the 
female 10 to 18 mm. The head, which 
tapers somewhat, is turned toward the back ; 
the mouth capsule is hollowed out and sur- 
rounded by four teeth ; the tail of the male 
forms a three-lobed bursa, while that of the 
female tapers conically ; the genital opening 
is behind the middle of the body. Its eggs 
have an oval form and a smooth surface, 
measuring 0.05 to 0.06 by 0.03 to 0.04 mm. 
In their interior two or three segmenting 
bodies are found, which rapidly develop out- 
side of the human body, so that after twenty - 

n ■ , n , • i , i i i a, male, slightly magnified ; b, 

IOUr to forty-eight hours embyros may be female, slightly magnified ;c, eggs 

found in the same feces in which the eggs ^TeS) 6 IL ' ° bjective 8 A ' 
were observed, or fully developed ova may 

be found after allowing the feces to stand for onlv a few hours. 
Trichocephalus hominis, Schwank, syn. y trichocephalus dispar (R,u- 
dolphi) ; mastigodes (Zeder) ; trichuris (Buttner). This parasite, 
which belongs to the family trichotrachelides, is formed like a whip, 
the last-end being the head-end, while the tail-end is very much 
thicker. The male measures 46* mm. and the female 50 mm, in 
length. The eggs are brownish in color, measuring O.Oo by 0.06 mm. 
in size, and presenting a doubly contoured shell, with a depression at 
each end, closed by a lid. The contents are coarsely granular. It is 
said to be the most widely distributed intestinal parasite, occurring 
in Europe, North America, Asia, Africa, and Australia. Its habitat 
is in the csecum. The living worm is onlv rarely found in the feces. 




Trichocephalus dispar. 
(v. Jaksch.) 



234 THE FECKS. 

Trichina spiralis (Owen) (Fig. 60) is rarely found in the feces. 
The male measures 1.5 mm. in length, and is provided with four 
papilla? between the conical lips. The female is 3 mm. long. The 
uterus is situated nearer the head than the ovary, which opens into 
it. Fertilization occurs in the intestinal canal. The eggs develop 
into embyros in the uterus, emerge from this, and penetrate the in- 
testinal walls, whence they are carried by the blood-current to the 

Fig. 60. 




l /£& 



- 



kl 




Trichina spiralis in muscle. 



muscles. Trichinosis is far less common in the United States than 
in Europe. 

Arupiillula irdestinalis is 2.25 mm. long and 0.04 mm. broad: its 
mouth is three-cornered and bounded by three little lips. -*■ The 
genital aperture is located between the middle and posterior third of 
the body. Its eggs are similar to those of anchylostomum duodenale, 
but longer and more elliptical, with tapering poles : they are never 



PATHOLOGY OF THE FECES. 



235 



Fig. 61. 



found in the feces, only the embryos occurring here. When sexually 
mature the parasite is called anguillula stercoralis ; this again gives 
rise to embryos, which may in turn enter the intestinal canal. The 
anguillula stercoralis (Fig. 61) has a rounded body, which presents 
an indistinct cross-striation. Its head is like the top of a cane and 
provided with two lateral jaws, each of which is armed with two- 
teeth. The male measures 0.08 mm., 
the female 1.22 mm. in length. The 
pathologic significance of this para- 
site has not yet been definitely ascer- 
tained, but from its resemblance to 
anchylostomum duodenale it has 
become important from a diagnostic 
point of view. 

Insecta. — As the larva? of the 
various insects met with in the feces 
have so far been very little studied, 
they will not be considered at this 
place ; they are apparently of no 
clinical importance. 

Vegetable Parasites. — Among the 
pathogenic vegetable parasites the 
bacillus of cholera, of typhoid fever, 
and of tuberculosis, as well as the ba- 
cilli of Booker, the bacillus coli com- 
munis, the bacillus pyocyaneus, the 
bacillus lactis aerogenes, and the 
proteus vulgaris deserve especial 
consideration. 

As early as 1848 certain " vib- 
rios" were observed in abundance 
in the stools of cholera patients by 
Virchow, and in 1849 by Pouchet, 
Britton, and Swayne, no importance, 
however, being attached to their 
presence at the time. 

The first accurate and detailed 
studies of the organism found in 
cholera stools were made in 1883 by the members of the French ami 
German commissions sent to Egypt to investigate the nature of the 
dreaded disease. The results of their work were first published by 
Koch in his report to the Berlin Sanitary Office in L883, and in 18S4 
by Strauss, Roux, Nocard, and Thuilller. 

The clinical recognition of cholera Asiatica has become a fairly 
simple matter, since Pfeiffer demonstrated that the blood-serum of 




Anguillula stercoralis. (BlZZOZERO. 



236 THE FECES. 

cholera patients possesses the property of causing arrest of motility 
and the agglutination of the specific bacilli. Bouillon-cultures, how- 
ever, can usually not be employed, as particles of the film, when 
broken up, may easily be mistaken for agglutinated bacilli. It is 
best in every case to make use of agar-cultures sixteen to twenty- 
four hours old, and to prepare emulsions in bouillon or normal salt- 
solution as occasion requires. The emulsion, moreover, should 
always be examined microscopically before use, so as to insure the 
absence of any conglomerations of bacilli. The blood is then diluted 
in the proportion of 1 : 10 or 1 : 15. If the test-tube method is 
employed, the tubes should only be kept in the incubator (37° C.) 
for one or two hours. Upon the slide the reaction is obtained in 
from five to twenty minutes. If no distinct agglutination is observed 
at the end of one hour, the diagnosis of cholera is rendered im- 
probable. Dried blood retains its agglutinating properties for a 
considerable length of time, and may also be used for examination. 

The comma bacillus is a slightly arched or half-moon-shaped little 
rod and somewhat shorter than the tubercle bacillus (Plate XI., 
Fig. 1). Occasionally two are placed end to end with their convexi- 
ties in opposite directions, thus presenting the appearance of the let- 
ter S. Koch detected these bacilli in the intestinal contents and feces, 
but rarely in the vomited matter, in Asiatic cholera only. In the 
stools they at times occur in such numbers as to constitute pure cul- 
tures. In plate-cultures, kept at a temperature of 22° C, white col- 
onies- with serrated borders may be observed after twenty-four hours. 
The color of such a colony is slightly yellow or rose-red, its central 
portion gradually assuming a deeper tint, and finally becoming lique- 
fied. Upon agar-plates the bacilli form a grayish-yellow, irregular, 
slimy coating, but do not liquefy the. culture-medium. In stab- 
cultures, after twenty-four hours, a whitish color may be observed 
along the line of the stab ; around this there is formed a funnel-shaped 
depression, which gradually increases in size and apparently contains 
a bubble of gas. The upper portion of the culture-medium at the 
same time becomes liquefied, while the lower portion remains solid for 
days. In a suspended drop spirochaetae-like spirals are observed at 
the margins, which often present as many as twenty distinct arches. 

Closely related to Koch's comma-bacillus, and possibly bearing to 
cholera nostras the same relation that the former bears to cholera 
Asiatica is the bacillus of Finlder and Prior, discovered in 1884 and 
1885 (Plate XL, Fig. 2). This is, however, readily distinguished 
from the former by the following characteristics : It is larger and 
thicker than the comma bacillus ; the colonies on gelatin plate-cul- 
tures show equally round and sharp-edged forms, which present a 
granular appearance under a low or medium power, and are usually 
of a brown color. The organism liquefies gelatin very rapidly, a 



PLATE XI 



(l''\\<^ A>\ 



Spirillum of Asiatic Cholera. Impression Cover-slip front a Colony 
Thirty- four Hours Old. (Abbott.) 



FIO. 2. 



Bacillus of Finkler and Prior. (Cornil and Babes.) 



FIG. S. 






Bacillus of Typhoid Fever from a Culture Twenty-four Hours Old 
on A.gar-agar, (Abbott.) 



PATHOLOGY OF THE FECES. 237 

penetrating excessively fetid odor being developed at the same time. 
In stab-cultures the bacillus of cholera Asiatica forms a funnel-shaped 
depression, while the bacillus of Finkler and Prior forms a stocking- 
like depression. Further work, however, is still necessary in this 
direction. 

The Typhoid Bacillus, discovered by Eberth in 1880 in the ab- 
dominal organs of patients dead with typhoid fever, is unfortunately 
not so readily recognized in the feces as the organisms just described. 
This is owing to the intimate relation which apparently exists be- 
tween the bacillus in question and the bacillus coli communis, with 
which it has many properties in common. A few years ago Eisner 
suggested a method which, it was hoped, would effectually overcome 
this difficulty, and in the hands of numerous observers good results 
were obtained. Widal's agglutination test, however, which was 
almost simultaneously introduced, diverted attention from the study 
of the feces, and Eisner's work has practically been forgotten. 

In the meantime Widal's test has been carefully investigated,. 
and although the reaction must unquestionably be considered as a 
specific reaction of typhoid fever, its value in diagnosis is neverthe- 
less limited (see p. 100). As a consequence, further attempts have 
been made to discover a method which will enable the general prac- 
titioner to definitely establish the diagnosis of typhoid fever at an 
early stage of the disease. Whether or not Eisner's method (v. i.) 
has been deservedly abandoned further investigations will show. At 
the present time another procedure, which was suggested by Pior- 
kowski is attracting widespread attention, as it is claimed that with 
this method the diagnosis can be made within 24 hours. 

Piorkowski's method : The necessary culture medium is prepared 
as follows : Normal urine of a specific gravity of about 1.020 is 
allowed to stand until the reaction has become alkaline. It is then 
treated with 0.5 per cent, of peptone and 3.3 per cent, of gelatin, 
boiled for one hour and filtered immediately into test-tubes, without 
any further application of heat. The test-tubes are closed with cot- 
ton, sterilized for 15 minutes in a steam sterilizer, at 100° C, and 
resterilized after 24 hours for 10 minutes. 

To examine the feces one tube is inoculated with two oesen of the 
fecal material, which should be as fresh as possible. From this tube 
four oesen are transferred to a second tube, and a third is inoculated 
witli from (> to 8 oesen from the one preceding. Plates are finally 
prepared and kept at a temperature of 22° C, as the presence of so 
small an amount of gelatin does not permit of exposure to higher 
temperatures. After 16 to 24 hours an examination is made with a 
low power. At the expiration of this time the colonies of the colon 
bacillus appear as round, yellowish-brown, and finely granular specks, 
with well-defined borders, while the typhoid colonies show a pecu- 



238 THE FECES. 

liar flagellate appearance, from 2 to 4 fine colorless radicles usually, 
starting from a light, highly refractive central focus. After 48 
hours the radicles have greatly extended, and after 48 to 56 hours 
the colonies are perfectly developed and present a picture which 
strongly suggests the appearance of radishes, minute interweaving 
branches being given off in every direction, while no difference can 
be observed at this time between typhoid and colon bacilli which 
have been grown for control in 1 0-per-cent. normal — or bouillon 
gelatin. 

Piorkowski claims that he has thus been able to demonstrate the 
presence of typhoid bacilli in infected drinking water, and in the 
feces of typhoid fever patients at a time when a positive result 
could not yet be obtained with Widal's test. 

Eisner's method : The culture medium is prepared as follows : 
An aqueous extract of potato (500 grammes to the litre) is treated 
with 10 per cent, of gelatin and boiled. The solution is then treated 
with 2.4 to 3.2 c.c. of a one-tenth normal solution of sodium hy- 
drate, in order to secure the necessary degree of acidity, and then 
filtered and sterilized. 

When needed, a portion is placed in an Erlenmeyer flask and 
treated with 1 per cent, of potassium iodide. The mixture is inocu- 
lated with fecal material and the necessary plates prepared. Upon 
this medium only a few species of bacteria will grow, principally the 
bacillus coli and the typhoid bacillus. After twenty-four hours the 
bacillus coli colonies are already mature, while the typhoid colonies 
can scarcely be made out with a low power. After forty-eight hours, 
however, they appear as small, highly refractive, extremely fine, 
granular colonies, closely resembling drops of water, which can be 
readily distinguished from the large, much more granular, brownish 
colonies of the bacterium coli. This difference is brought out par- 
ticularly well if diluted plates have been prepared. 

Brieger, who carefully repeated the experiments of Eisner, states 
that typhoid bacilli are found in abundance in the stools so long 
as fever exists, but with approaching convalescence they dimin- 
ish in number and ultimately disappear. If, notwithstanding the 
absence of fever, bacilli are found in notable numbers during conva- 
lescence, a relapse may be anticipated. 

In pure cultures the typhoid bacilli present the following features : 
They occur in the form of rods of almost one-third the size of a red 
blood-corpuscle, or in threads composed of several rods, joined end 
to end (Plate XL, Fig. 3). The ends are rounded off; their 
length is equivalent to about three times their breadth. They are 
actively motile and provided with polar as well as lateral flagella. 
They grow very readily on bouillon-peptone gelatin, and after 24 
hours colonies begin to appear. When slightly magnified these 



PATHOLOGY OF THE FECES. 239 

present a faintly yellowish color ; microscopically they are barely 
visible. When kept at a temperature of 37° C. the formation of spores 
may be observed, especially when the organism is grown on media 
colored with phloxin-red, or benzopurpnrin. Gelatin is not lique- 
fied. Cultivation in glucose bouillon, in fermentation tubes, does 
not give rise to the formation of any gas, but after 24 hours the en- 
tire fluid becomes turbid. Milk is rendered feebly acid, but is not 
coagulated. No indol reaction is obtained, when the organism is 
grown on peptone-containing media. Absolute identification is pos- 
sible by means of Pfeiffer's agglutination test (see WidaPs reaction). 

Tubercle bacilli, when present in the feces, are indicative of intestinal 
tuberculosis, providing they are observed upon repeated examination 
and there are clinical symptoms pointing to the bowels as the seat 
of the disease, as otherwise they may be referable to swallowed sputa. 
They may be demonstrated, as described in the chapter on Sputum. 

In this connection the green bacillus of Le Sage, discovered in certain 
forms of infantile diarrhoea, must be briefly referred to, the stools, as 
has been mentioned, being of a grass-green color. The production 
of this pigment in cultures is one of the characteristics of the organ- 
ism ; when injected into the intestines of animals it is said to produce 
diarrhoea and a catarrhal inflammation of the mucous membrane. 

Booker has described nine different bacilli, as occurring in cases of 
infantile diarrhoea. Seven of these closely resemble the bacillus coli 
communis. Bacillus " A " is a bacillus with rounded ends, measur- 
ing from 3 fi to 4 p. in length by 0.7 g in breadth. It is motile and 
liquefying. Colonies on agar and potato present a dirty-brown color. 

The bacillus coli communis, while constantly present in normal 
feces, is described at this place, as modern investigations have shown 
that it may at times develop pathogenic properties. It has been 
found in the pus in cases of purulent perforating peritonitis, angio- 
cholitis, pyelonephritis, etc., and, as indicated elsewhere, at times 
forming the nucleus of gallstones. It occurs in the form of delicate 
or coarse rods, measuring about 0.4 g in length, which manifest a 
certain degree of motility, due to the presence of one or two polar 
flagella. The organism is stained by the usual anilin dyes, and is 
decolorized by Gram's method. The colonies upon gelatin closely 
resemble those of the bacillus of typhoid fever, forming small whitish 
specks in the gelatin, and delicate films with serrated borders upon the 
same medium, which, moreover, is not liquefied. They also grow upon 
potato. As in the case of the cholera bacillus the nitroso-indol reaction 
can be obtained when the organism is grown upon peptone-containing 
media. In solutions of glucose active fermentation takes place. 

The bacterium lactis arrogates (Esoherich) closely resembles the 
organism just described, and may also at times develop pathogenic 
properties. It was recently found in a case of pneumaturia and in 



240 THE FECES. 

one of idiopathic bacteriuria. It is seen quite constantly in the 
stools of sucklings, but may also be met with in those of adults. 
It occurs in the form of rather stout rods, which frequently lie in 
pairs, resembling diplococci. The organism is non-motile. Like 
the bacillus coli communis it is decolorized by Gram's method. In 
plate-cultures it forms a dense white film ; in stab-cultures a chain 
of white colonies resembling beads is seen. In the latter, moreover, 
if the stab is closed, bubbles of gas will be seen to form, which rap- 
idly increase in number and size. Milk is coagulated in large lumps 
in twenty-four hours ; the formation of gas is, at the same time, much 
more intense than in the case of the bacillus coli communis. 

The bacillus pyocyaneus has within recent years been isolated from 
the stools of dysenteric patients, and has been proven the cause of 
several epidemics. The organism in question is a small motile bacil- 
lus measuring from 1—2 fi in length by 0.3—0.5 fi in breadth. It 
sometimes occurs in short chains, but is usually single. It is stained 
with the common anilin dyes, and is decolorized with Gram's 
method. It grows on the usual culture media, and liquefies gelatin. 
In 2-per-cent. glucose-bouillon no fermentation takes place. Litmus- 
milk is curdled in about forty -eight hours. Some varieties produce 
indol. Most characteristic is the production of certain pigments, viz, 
pyocyanin and a fluorescent bluish-green pigment, which is common 
o almost all varieties. 

Proteus vulgaris, Hauser. This organism, while usually regarded 
as non-pathogenic, should be numbered among the bacteria which 
may at times develop pathogenic properties. Baginsky and Booker 
have frequently found it in the stools in cases of infantile summer 
diarrhoea. Escherich observed it at times in the meconium. Others 
have encountered it in inflammatory conditions of exposed surfaces, 
in appendicitis, in perforative peritonitis, and even in closed abscesses, 
either alone or in association with other bacteria (Welch). A mixed 
infection of the proteus and Loffler's bacillus has also been observed. 
The organism forms little rods, measuring about 0.6 p. in diameter, 
while their length is variable ; at times a more roundish form is ob- 
served ; at others little rods measuring from 1.25 fi to 3.75 ju in 
length, or even long threads. They are readily stained, but are 
easily decolorized by alcohol or Gram's method. Most characteristic 
is their growth upon nutrient gelatin. At the temperature of the 
room little depressions will be observed after six to eight hours, which 
are surrounded by a narrow zone of bacilli from which a thin, wide 
film, provided Avith irregular projections, extends over the culture- 
medium. From this film small islets become separated, which slowly 
extend over the gelatin and cause its liquefaction. The organism 
is motile. It decomposes urea and causes albuminous putrefaction. 
The nitroso-indol reaction is readilv obtained in bouillon-cultures. 



PATHOLOGY OF THE FECES'. 241 

Chemistry of the Feces. 

According to Hoppe-Seyler, mucin is a constant constituent of the 
feces, both under physiologic and pathologic conditions, formally, 
however, it is never possible to recognize its presence either with the 
naked eye or with the microscope. In order to demonstrate the pres- 
ence of mucin in the feces they are digested with water and treated 
with an equal volume of milk of lime ; the mixture is allowed to 
stand for several hours, when it is filtered and the filtrate tested with 
acetic acid. In the presence of mucin a cloud develops upon the ad- 
dition of the acid. 

Albumin is demonstrated in the feces by treating them repeatedly 
with water slightly acidified with acetic acid. The filtrate is then 
examined for albumin according to methods given elsewhere (see 
Urine). Under normal conditions these reactions prove negative. 
Pathologically, serum -albumin has been observed in cases of typhoid 
fever and chlorosis. 

Peptones are normally absent from the feces. They have been 
observed in typhoid fever, dysentery, tubercular ulceration, purulent 
peritonitis with perforation into the gut, atrophic cirrhosis, and car- 
cinoma of the liver. Acholic stools are also usually rich in peptones. 

The peptones are demonstrated in the following manner : The 
feces are digested with water, so as to form a thin mush ; they are 
then boiled, filtered while hot, and the filtrate exauiined for albumin, 
so as to be sure that all of this has been removed. The mucin is re- 
moved by treating with acetate of lead, when the filtrate is examined 
for peptones as described in the chapter on Urine (which see). 

Among the carbohydrates, starch, glucose, and certain gums may 
be found. In order to demonstrate these the feces are boiled with 
water, filtered, and evaporated to a small volume. This solution 
may now be tested with phenylhydrazin or Trommer's reagent for 
the presence of glucose (see Urine), and with a solution of iodo- 
potassic iodide for starch (see Saliva, p. 123). The residue is ex- 
tracted with alcohol and ether, as described under the heading; of 
fatty acids, and then with water. The filtrate of the aqueous extract 
is concentrated, boiled with dilute sulphuric acid, and then over- 
saturated with sodium hydrate. This mixture is treated with sul- 
phate of copper and boiled in order to test for dextrin and gums. 

Bile-pigment, which is normally absent from the feces, occurs in 
large amounts in catarrhal conditions of the small intestine, and may 
be demonstrated by Gmelin's method, viz, a drop of the filtered 
liquid, or a particle of highly colored fecal matter, is brought into 
contact with a drop of fuming nitric acid, when the yellow color will 
be seen to pass through the various shades of the spectroscope, the 
green shade being the most characteristic. 
16 



242 THE FECES. 

At times, however, it is not possible to obtain a positive reaction 
in this manner, although bile-pigment is present. In such cases the 
examination should be conducted under the microscope, and attention 
directed to bile-stained epithelial cells, leucocytes, particles of mucus, 
and crystals. 

Whenever there is increased intestinal putrefaction the fatty acids, 
phenol, indol, and skatol will, of course, be found in increased 
amounts. 

Ptomains. — Of ptomains only two have been isolated from the 
feces, under pathologic conditions, viz, putrescin and cadaverin. 
They have been found in Asiatic cholera, in cholerina, dysentery, 
and in connection with cystinuria. In cholera and cystinuria their 
amount may be quite large. Baumann and v. Udranszky thus ob- 
tained 0.5 grm. of the benzoylated compounds from the collected 
feces of twenty-four hours. In cholera the cadaverin seems to pre- 
dominate, while in cystinuria more putrescin is found. 

To isolate the diamins in question the feces are digested with 
alcohol which has been acidified with sulphuric acid. The alcoholic 
extract is evaporated, the residue dissolved in water and further 
benzoylated, as described in the section on Urine. 

THE FECES IN VARIOUS DISEASES OF THE 
INTESTINAL TRACT. 

Acute Intestinal Catarrh. — This condition follows the ingestion 
of excessive quantities of normal food, of tainted food (meat, fish, 
cheese, etc.), beer, and of certain poisons, such as acids, alkalies, 
arsenic, corrosive sublimate, etc., when taken in toxic quantities. 
It is also observed as the result of a general infection, as in summer 
diarrhoea, cholera nostras, typhoid fever, and severe malaria, and is 
associated with disturbed circulatory conditions, producing a passive 
hyperemia of the gastro-intestinal mucosa, as in diseases of the liver 
and portal system, in chronic heart and lung diseases, etc. How far 
these circulatory disturbances may be considered as primary causes 
remains to be seen. Possibly they merely act as predisposing causes 
of certain chemical processes taking place in the intestinal contents. 

The stools are usually increased in number in proportion to the 
degree in which the large intestine is affected. Two or three, or 
ten or more, stools jnay be passed within the twenty-four hours. 
In consistence they are mushy or even watery, containing in some 
cases 90 or 95 per cent. Their color is usually light yellow, but 
may, at times, be green. Microscopically, remnants of food may 
be found in large quantities, as also numerous bacteria, triple phos- 
phates, isolated pus-corpuscles, and desquamated cylindrical epithe- 
lial cells. 



FECES IN VARIOUS DISEASES OF THE INTESTINAL TRACT. 243 

A duodenal catarrh can only be diagnosed when icterus exists at 
the same time. 

In catarrh of the jejunum and ileum, when the large intestine is not 
affected, the stools are firm, formed, and speckled with small hyaline 
particles of mucus, which are visible only with the microscope. Usu- 
ally, however, the large intestine is also affected, when the stools are 
loose and contain undigested particles of food, the latter indicating 
abnormal conditions in the small intestine. Bile-pigment is also 
met with, as the contents of the small intestine only give Gmelin's 
reaction. 

Catarrh of the large intestine probably always exists whenever 
diarrhoea occurs. 

When the colon is extensively affected mucus appears in larger 
masses than otherwise, and if the catarrh is very low down the feces 
may be formed, but are covered with mucus. 



Fig. 62. 



..■•#^%- ; .v,V:v^'%.:;' V 



"V - ' ' •'• -'.'-*^~ '• ' - j^Jl'; ! :-^M- 










Rectal discharge from a case of enteritis membranosa. 

Chronic Intestinal Catarrh. — This may follow an acute attack, 
and may also occur after dysentery, severe malaria, typhoid fever, 
etc. Diarrhoea usually alternates with constipation. It is not very 
common in adults, while in children it is quite frequently observed. 
Macroscopically and microscopically it presents the same picture as 
in the acute form. 

Enteritis 'membranosa is a form of chronic intestinal catarrh, which 
is essentially characterized by the evacuation of cylindrical masses of 
mucus, as described on p. 211 (Fig. 62). 

Cholera Nostras. — This is an infectious disease affecting both 
stomach and intestines, and probably dependent upon the presence 
of the bacillus of Finkler and Prior. 

The stools are first feculent, but soon become colorless and more 
and more watery, until they ultimately resemble the so-called rice- 
water stools of cholera Asiatica, and contain much serum-albumin 
and mucin. 



244 THE FECES. 

Summer Diarrhoea of Infants, — In this disease six or seven 
stools are passed daily, which are more liquid than normally, of a 
fetid odor, and contain flakes of casein. They are often green when 
passed, or may assume that color on standing. Mucus is present, 
and when the colon is especially affected may occur in sago-like par- 
ticles. In severe forms pus-corpuscles, epithelial cells, and small 
amounts of blood may be present. 

Booker, in his classical work on the summer diarrhoea of infants, 
arrives at the conclusion that the disease in question cannot be at- 
tributed to the presence of any one particular micro-organism, but 
that the " affection is the result of the activity of a number of vari- 
eties of bacteria, some of which belong to well-known species and 
are of ordinary occurrence and wide distribution, the most impor- 
tant being the streptococcus and proteus vulgaris." He also found 
that in the colon the bacillus lactis aeroeenes occurs in greater num- 
ber than in the normal intestine, and that it may even predominate 
over the bacillus coli communis. Among other forms of bacteria 
which occur frequently and in great abundance are small, short, 
faintly staining bacilli ; long, very slender bacilli ; large bacilli with 
pointed ends, and small, faintly staining spirilla. 

Dysentery. — This is an infectious disease, and possibly caused by 
a bacillus discovered by Chantemesse and Widal. The stools during 
the first few days are irregular. A moderate diarrhoea then sets in ; 
the stools are thin, but still feculent, and number from five to six per 
diem. After several days the diarrhoea increases and the stools 
now assume a definite character, numbering from ten to twenty or 
even fifty or sixty in the twenty -four hours. At the same time 
they become scanty in amount, usually not exceeding 10 or 15 
grammes at a time. They are now sero-sanguineous in character, 
and in them may be found smaller or larger pieces of necrotic 
tissue. Microscopically blood-corpuscles, particles of mucus, pus- 
corpuscles, and numerous bacteria are seen. According to the pre- 
ponderance of blood, pus, mucus, etc., the stools are termed sanguine- 
ous, sero-sanguineous, putrid, or mucoid, etc. Shreds of mucus, 
resembling frogs' eggs or kernels of tapioca, which are, in all prob- 
ability, casts of follicles, are also found. Typical dysenteric stools 
do not, as a rule, emit a marked odor, but in the gangrenous form 
they are very offensive. 

Amcebic Dysentery. — This form of dysentery is especially inter- 
esting, not so much on account of its prevalence, however, as of the 
importance attaching to an early diagnosis, as successful treatment is 
altogether dependent thereupon, and differs materially from that em- 
ployed in the more usual forms. 

The number of stools may vary within very wide limits — from six 
to twentv or even thirty in the twenty-four hours. They mav be 



FECES IN VARIOUS DISEASES OF THE INTESTINAL TRACT. 245 

wholly mucoid, streaked here and there with pus, and presenting a 
few grayish threads. Others seem to be made up of a greenish, 
pultaceous mass, in which at times large greenish, irregular sloughs 
are observed. Such stools are usually slight in amount. Occasion- 
ally large brownish, liquid evacuations are seen, in which smal 
grayish- white masses occur, imbedded in blood-stained mucus. Such 
stools contain the diagnostic amoebae most abundantly. 

For a satisfactory examination the bed-pan should be well warmed 
and brought to the laboratory immediately for examination. If this 
is impractical, some of the material may be deposited in a suitable 
receptacle, and the small, grayish- white masses placed upon a warmed 
slide, if a warm stage is not at hand. One preparation after another 
must now be carefully looked over for actively moving amoebae, or 
for amoeba-like bodies which exhibit definite movements. (For a 
description of these parasites see page 217.) 

In addition to the amoebae other animal parasites may also be met 
with, such as the trichomonas intestinalis, which is at times present 
in very large numbers. 

Red blood-corpuscles in greater or less abundance, numerous pus- 
corpuscles, more or less degenerated cylindrical epithelial cells, 
bacteria of all kinds, and even large pieces of necrotic tissue may be 
found. 

Cholera Asiatica. — In this disease the stools are very numerous, 
being at first feculent, but soon becoming rice-water like. As large 
a quantity as 200 grammes may be passed at each evacuation. The 
stools are colorless, almost odorless, watery, and on standing a finely 
granular, grayish- white sediment may be seen to form at the bottom. 
The reaction is neutral or alkaline. They contain only 0.5 per cent, 
of solids, a little serum-albumin, and a large amount of sodium 
chloride. In severe cases blood is present in variable amount. 
Microscopically, epithelial cells, triple phosphate crystals, and numer- 
ous micro-organisms are found. Of the latter the comma-bacillus 
is, of course, the most important (see p. 236). 

Typhoid Fever. — Typhoid stools are usually described as re- 
sembling pea-soup both in consistence and color. Their odor is 
generally highly offensive and characteristic. They contain a large 
amount of biliary coloring-matter and have almost always an alkaline 
reaction. Microscopically many bile-stained epithelial cells, some 
leucocytes, many triple phosphate crystals, and an enormous number 
of micro-organisms, especially the Clostridium butyricum oi' Xoth- 
nagel and Eberth's bacillus, are found. Later on they may assume 
the, appearance of ulcerative stools and become almost black, owing 
to the presence of blood. 



246 THE FECES. 

MECONIUM. 

By meconium are meant those masses which are first excreted from 
the bowel after birth. It is a thick, tenacious, greenish-brown mate- 
rial, which has accumulated during the intra-uterine life of the infant. 
Microscopically a few cylindrical epithelial cells, a few fat-droplets, 
numerous cholesterin-crystals, bilirubin-crystals, and lanugo-hairs 
are found. 

Micro-organisms are absent, but soon after suckling has com- 
menced they appear in abundance. The most important ones of those 
which are then constantly present are the bacillus lactis aerogenes, 
which predominates in the small intestine, and the bacillus coli 
communis, which is found more particularly in the large intestine. 
Both have already been described (see p. 39). 

In addition to these proteus vulgaris, streptococcus coli brevis, 
micrococcus ovalis, tetradencoccus, torula cerevisise, torula rubra, 
and a few less important micro-organisms have been found. 

Chemically meconium contains bilirubin in considerable amount 
(recognizable by Gmelin's reaction), biliary acids, fatty acids, 
chlorides, sulphates, phosphates of the alkalies and their earths. 
It does not contain urobilin, glycogen, peptones, lactic acid, tyrosin, 
or leucin. 

An idea may be formed of its composition from the following 
table of Zweifel : 

"Water ....... 79.8-80.5 per cent. 

Solids . .... 19.5-20.2 

Mineral matter . . . 0.978 " 

Cholesterin . . . 0.797 " 

Fats . ... 0.772 



CHAPTER V. 
THE NASAL SECRETION. 

In the nasal secretion, which is small in amount, transparent, 
colorless, odorless, tenacious, and of a slightly saline taste, pave- 
ment-epithelial cells in large numbers, ciliated epithelial cells, as well 
as some leucocytes and an enormous number of micro-organisms, are 
found (Fig. 63). Its reaction is alkaline. 

Fig. 63. 




Epithelial cells and mucous corpuscles found iu the nasal secretion. 

In acute coryza the amount is at first diminished, but soon a very 
copious secretion occurs, which contains numerous epithelial cells 
and micro-organisms. When complicated with an ulcerative condi- 
tion pus is observed in considerable amount. 

Occasionally, as in cases of traumatism, cerebral tumors, etc., 
cerebro-spinal fluid is discharged through the nose, and may be 
recognized by the fact that it is free from albumin and contains a 
substance which reduces Folding's solution. 

Of pathogenic organisms the tubercle bacillus and the bacillus of 
glanders may occur in ulcerative diseases of the nose, their presence 
indicating the existence of the corresponding affection. In ozsena a 
large diplococcus has been described by Lowenberg, which is said to 
be characteristic of the disease. Oidium albicans has boon observed 
in rare cases. The meningococcus intraeellularis of Weichselbaum, 
which is now quite generally regarded as the cause o\' epidemic 
cerebro-spinal meningitis, has also boon demonstrated in the nasal 

247 



248 THE NASAL SECRETION. 

secretion of healthy individuals. This fact helps to explain the 
origin of those cases of meningitis which develop after injuries to 
the skull. 

Ascarides and other entozoa have also been found. The Charcot- 
Leyden crystals (see p. 196) have been observed in the nasal secre- 
tion in cases of bronchial asthma, and in connection with nasal 
polypi. Their presence is usually accompanied by the simultaneous 
occurrence of eosinophilic leucocytes. 



CHAPTER VI. 
THE SPUTUM. 

General Technique. 

The sputum should be collected in suitable receptacles, constructed 
in such a manner as to permit of their complete and easy disinfec- 
tion. The paper spit-cups (Fig. 64) which have been introduced 
within late years are admirably adapted to this purpose, as they may 
be destroyed immediately after use. 

Fig. 64. 





Sanitary spit-cup. 

When working with sputa which are known or suspected to be of 
tubercular origin, the greatest care should be exercised, to keep the ex- 
pectoration from drying and becoming disseminated in the air. Negli- 
gence in this respect may result in the most serious consequences. 

The macroscopic examination of sputa is most conveniently carried 
out by placing small portions of the material upon a plate of ordinary 
window-glass, of suitable size, which lias been painted black upon 
its lower surface, and covering the same with a second, smaller 
plate. If it is desired to examine individual constituents which 
have been discovered in this manner, the upper plate is slid off until 
the particle in question is uncovered, when it may be removed to a 
microscopic slide and examined under a higher power. 

249 



250 THE SPUTUM. 

It is also very convenient to have a portion of the laboratory table 
painted black, when unstained plates of glass may be utilized. If 
these measure about 15 by 15 cm. and 10 by 10 cm., respectively, 
fairly large quantities of sputum may be examined in situ with a low 
power. 

General Characteristics of the Sputa. 

The Amount. — The amount of sputum expectorated in the twenty- 
four hours varies within very wide limits, depending largely upon 
the nature of the disease. Thus, only a few c.c. may be eliminated, 
or the amount may reach 600 to 1,000 c.c, and even more. Very 
large quantities are expectorated in cases of pulmonary hemorrhage 
and oedema of the lungs, also following the perforation of accumu- 
lations of pus from the thoracic or abdominal cavities into the respi- 
ratory passages ; furthermore, in cases in which large vomicae of 
tubercular or gangrenous origin exist, and finally in cases of abscess 
of the lung, bronchiectasis, and even in simple bronchial blennorrhoea. 
In incipient phthisis, acute bronchitis, and in the first and second 
stages of pneumonia, on the other hand, the amount is usually small. 

In private practice, as well as in hospital work, an idea should 
always be formed of the amount expectorated in the twenty-four 
hours, especially in cases in which this is abundant. It is apparent 
that a copious and long-continued expectoration cannot go on without 
exerting very detrimental eifects upon the patient's general nutri- 
tion ; in cases of pulmonary phthisis, for example, Renk has shown 
that 3.8 per cent, of all nitrogen eliminated in such cases is removed 
in this manner. Lanz in his recent experiments even found 5 per 
cent. 

Consistence. — The consistence of the sputum corresponds, in a 
general way at least, to its amount, and may vary from a liquid to a 
highly tenacious state. The cause of the tenacity of the sputum is 
but imperfectly understood. The mucin present does not appear to 
be the most important factor, as this has been observed to occur in 
diminished amount in pneumonic sputa, which are noted for their 
high degree of tenacity. Kossel has suggested that this phenomenon 
may be due to the presence of nucleins or nuclein derivatives, while 
others again refer it to the presence of abnormal albuminous bodies 
of unknown character. However this may be, sputa are at times and 
not at all infrequently seen, where it is possible to invert the cup 
without loosing a drop of its contents. This is observed especially in 
cases of acute croupous pneumonia up to the time of the crisis, pro- 
viding that a catarrh of the bronchi does not exist at the same time. 
It is noted, furthermore, in cases of acute bronchial asthma, immedi- 
ately after an attack, and also in the initial stage of acute bronchitis. 

In cases of oedema of the lungs, on the other hand, the sputa are 



GENERAL CHARACTERISTICS OF THE SPUTUM. 251 

liquid and present the general characteristics of blood serum, being 
covered, like all albuminous liquids when brought into contact with 
the air, by a frothy surface-layer. The sputa observed in cases of 
acute pulmonary gangrene, pulmonary abscess, putrid bronchitis, and 
following perforation into the lungs of an empyema or an accumula- 
tion of pus situated beneath the diaphragm, are fluid and consist of 
pure pus. 

Color. — The color of the sputa may vary greatly. They may be 
perfectly clear and transparent, gray, yellow, green, red, brown, and 
even black. Purely mucoid expectoration is almost transparent and 
colorless, as is also the sputum of pulmonary oedema when not mixed 
with blood or pus. 

The larger the number of leucocytes the more opaque does the 
sputum become, assuming at first a white, then a yellow, and finally 
a greenish color, the two latter colors being usually indicative of the 
presence of pus. Green sputa, however, may also be observed when 
bile pigment has become admixed to the sputa, as in cases of perfo- 
ration of a liver-abscess into the lung. Green sputa may also be ob- 
served in cases of jaundice, and especially in pneumonia when accom- 
panied by icterus. In cases of amoebic liver-abscess with perforation 
into the lung the sputa present a color resembling anchovy sauce, 
which is very characteristic. In one case I could recognize the na- 
ture of the disease by simple inspection of the sputa. 1 

The inhalation of particles of carbon gives the sputum a grayish 
or even a black color ; the same or an ochre-yellow or red color is 
observed in cases of siderosis. 

A red color is usually indicative of the presence of blood, the in- 
tensity of the shade depending upon the character of the disease. 
It is seen especially after the formation of cavities, in caseous pneu- 
monia, in incipient phthisis, heart-disease, etc. In general it may 
be said that a clear, bright-red color indicates an arterial, a dark- 
red or bluish-red a venous origin of the hemorrhage. The exact 
shade will depend upon the length of time that the blood, no matter 
what its origin may be, has remained in the lungs. In pulmonary 
gangrene a dirty brownish-red color is observed, owing to the pres- 
ence of methsemoglobin, and, to some extent also, of hsematin. 
Quite characteristic is a chocolate-color, which is observed when a 
croupous pneumonia terminates in necrosis and gangrene. Equally 
characteristic is the rusty and prune-colored expectoration seen in eases 
of pneumonia. Occasionally a breadcrust-brown color is observed in 
cases of gangrene and abscess of the lung, which is quite character- 
istic, the color being due to the presence of hsematoidin or bilirubin. 

Rust-colored, punctate, or striped sputa, moreover, arc said to be 
diagnostic of brown induration of the lung. 

1 See Johns Hopkins Hospital Bulletin, November, 1890. 



252 THE SPUTUM. 

Odor. — Most sputa are odorless. Under certain conditions, how- 
ever, there may be a very marked odor. In cases of pulmonary 
gangrene or putrid bronchitis the odor is of a kind never to be for- 
gotten, the stench, indeed, being frightful. A somewhat similar, 
slightly sweetish odor is observed in certain cases in which putre- 
factive organisms have entered the lungs and there exert their action 
upon the accumulated sputa, in the absence of gangrene, as in cases 
of bronchiectasis, perforating empyema, and where ulcerative proc- 
esses are taking place in the lungs, whether these be of tubercular 
origin or not. An odor like that of old cheese is occasionally ob- 
served in cases of perforating empyema ; under such conditions 
tyrosin is usually found. This body, however, has nothing to do 
with the odor of the sputa ; both factors are merely indicative of 
certain putrefactive changes going on in the lungs. According to 
Leyden, the occurrence of tyrosin in sputa is usually indicative of 
the perforation of an old accumulation of pus into the lungs. 

Specific Gravity. — The specific gravity of sputa varies within 
wide limits ; mucous sputa have a specific gravity of 1.004 to 1.008, 
purulent sputa one of 1.015 to 1.026, and serous sputa one of 1.037 
or more. 

Configuration of Sputa. — As a general rule, the following forms 
of sputa, which may be termed pure sputa, present a homogeneous 
appearance : 

Mucoid sputa, 1 

o ? ' \ Homogeneous sputa, 

feerous sputa, ° r ' 

Sanguineous sputa, J 

with one exception, perhaps — the typically rusty sputa of croupous 
pneumonia ; while mixtures of any two or three of these may be 
classed as heterogeneous sputa : 

Muco-purulent sputa, ] 

Muco-serous sputa, -u- , 

o . * > , } Heterogeneous sputa. 

Sero-sangumeous sputa, ° F 

Sanguino-muco-purulent sputa, J 

The so-called sputum crudum of the first stage of acute bronchitis 
may be regarded as an example of a purely mucoid sputum. A 
purely purulent sputum is usually indicative of the perforation of an 
empyema or any other accumulation of pus into the lungs or bronchi, 
of pulmonary abscess, or of bronchial blennorrhoea. A purely serous 
sputum is found in cases of pulmonary oedema, and a purely hemor- 
rhagic sputum in cases of severe pulmonary hemorrhage. 

Of the heterogeneous sputa, the most important are the so-called 
nummular sputa of phthisis, in the second and third stages. These 
are characterized by the fact that, when thrown or expectorated into 



MACROSCOPIC CONSTITUENTS OF SPUTUM. 253 

water, they sink to the bottom and there form more or less roundish 
coin-like disks, from which property they have received their name. 
Such sputa are muco-purulent in character, and contain imbedded in 
a more or less homogeneous mass of mucus a focus of almost pure 
pus. Quite different from these are the so-called sputa globosa of 
the ancients, which consist of fairly dense, roundish, grayish-white 
masses ; they are secreted in old cavities which have become lined 
with a granulation-membrane. 

Very important is the presence of small, cheesy particles, which are 
occasionally found at the bottom of the spit-cup. They vary in size 
from that of a millet-seed to that of a pea, and are observed espe- 
cially in the second and third stages of phthisis. Usually they con- 
tain tubercle bacilli in large numbers, and frequently also elastic 
tissue. 

Not to be confounded with these, are certain small, caseous masses 
which are at times expectorated by perfectly normal individuals, and 
also by patients suffering from acute tonsillitis, ozsena, etc., and 
which probably come from the tonsils or mucous cysts. They were 
formerly regarded as tubercles, and in hypochondriac individuals 
their expectoration may cause a great deal of anxiety. They are 
quite readily distinguished from the true caseous masses expectorated 
by phthisical individuals by the following characteristics : As a rule, 
they are expectorated unaccompanied by any admixture of pus or 
even of mucus ; rubbed between the fingers they emit an extremely 
offensive odor, which is referable to the presence of fatty acids ; an 
examination for tubercle bacilli, moreover, will prove entirely nega- 
tive. Quite characteristic, furthermore, is the peculiar, finely floc- 
culent, granular appearance of the sputa seen after the perforation of 
an empyema into the lungs through a small aperture, which is not 
followed by pneumothorax. 

Occasionally, as in putrid bronchitis, and gangrene of the lungs, 
and also in chronic bronchitis, ultimately leading to the formation 
of bronchiectatic cavities, an exquisite sedimentation is observed. 
Such sputa, when collected in a conical glass, present three distinct 
zones : the one at the bottom contains the cellular elements of the 
sputum, the second the pus-serum, and the third or superficial 
layer consists of mucus and contains many air-bubbles. 

Macroscopic Constituents of Sputum. 

Elastic Tissue. — Of macroscopic constituents which may be ob- 
served in sputa there may be mentioned, first of all, the occurrence 
of threads of elastic tissue and pulmonary parenchyma, which are 
seen in cases of phthisis, pulmonary abscess, and gangrene. As 
their ultimate recognition, however, largely depends upon a micro- 
scopic examination, this subject will be considered later on. 



254 



THE SPUTUM. 



Fibrinous Casts. — Fibrinous casts are observed especially in 
cases of croupous pneumonia (Fig. 65), immediately before or after 
resolution has taken place. They are also seen in cases of so-called 
fibrinous bronchitis (Fig. 66), and in diphtheria, when the membrane 
has extended into the finest ramifications of the bronchi. These 
casts may vary in size from 12 cm. in length by several mm. in 
thickness to small fragments which measure only from 0.5 to 3 cm. 
in length. The fibrinous casts observed in cases of pneumonia, 



Fig. 65. 




Fibrinous coaguluni from a case of croupous pneumonia. (Bizzozero.) 

usually from the third to the seventh day, are of the latter size or 
even smaller, being derived from the ultimate twigs of the finest 
bronchioles. Those found in the rather rare disease, fibrinous bron- 
chitis, stand between these two in size, being casts of the smaller and 
medium-sized bronchi. Attention is usually attracted to the presence 
of such casts by their white color ; often, however, they are yellow- 
ish-brown or reddish-yellow, owing to the presence of blood-coloring 
matter which has become deposited upon the casts ; at other times 
they are enveloped in mucus, when their recognition may become 
quite difficult. Such casts, when examined more carefully, will be 
seen to branch dichotomously, and to contain a cavity in their larger 



MACROSCOPIC CONSTITUENTS OF SPUTUM. 255 

portion, while the finer branches appear to be solid. Microscopically 
they may be shown to consist of a large number of fibres, which are 
arranged longitudinally, or in a net-like manner, and contain blood- 
corpuscles and epithelial cells in their meshes. When treated with 
Weigert's fibrin-stain they are beautifully resolved. Charcot-Leyden 
crystals have at times been observed in these formations. 

Fig. m. 




Fibrinous coagulum from a case of plastic bronchitis, (v. Jaksch.) 

Whenever it is desired to examine sputa for casts it is best to pick 
out particles that look promising, upon a dark or light surface, and 
then to shake them out in water. For such purposes Kronig's 
sputum-plate can be strongly recommended. 

Curschmann's Spirals. — Quite distinct from the formations just 
described are the so-called spirals of Curschmann, which are ob- 
served especially in cases of true bronchial asthma, but also occur in 
chronic bronchitis, and even in croupous pneumonia. Upon careful 
examination they will be seen to consist of thick, yellowish-white 
masses, which exhibit a spirally twisted appearance, and are 
characterized, moreover, by their more solid consistence and light 
color. Microscopically, Curschmann's spirals arc composed of a 
spirally twisted network of extremely delicate fibrils, containing 
epithelial cells and numerous leucocytes ; the latter are almost all of 
the eosinophilic variety. Usually, but not invariably, Charcot-Ley- 



256 



THE SPUTUM. 



den crystals are also seen. The spirally twisted mass is found to be 
wound around a central, very light and clear thread, which usually 
has a zig-zag course (Fig. 67). 

Fig. 67. 



*«8ta&fe 



.^rnsrn^, 









^; 




A Curschuiann's spiral from a case of true bronchial asthma. 

Other formations, probably mere varieties of those just described, 
have also been observed, in which the central thread is absent or in 
which the spiral arrangement is deficient. The spiral form, how- 
ever, with the central thread, must be considered as the most char- 
acteristic. Their length and breadth may vary a great deal, but 
rarely exceeds 1 to 1.5 cm. Their occurrence seems always to indi- 




Fig. 69. 



Charcot-Levden crystals. 




Wall of a hydatid cyst, showing 
the laminated structure, not mag- 
nified. ( Davaixe. ) 



cate a desquamative catarrh of the bronchi and alveoli, but practically 
nothing is known concerning their formation. If, in a given case, 
the diagnosis rests between true bronchial and what may be termed 
reflex asthma, the presence of these formations points to the existence 
of the former disease. Chemically the spirally wound mass seems to 
consist of a mucinous substance, while the central thread is possibly 
of fibrinous origin. 






PLATE XII 



, ; - 



*9 






..£j. ^^ 



s ? 



#*'' 



C'., 



4p 






Sputum from a Case of Bronchial Asthma, showing large num- 
bers of Eosinophilic Leucocytes and Free Granules. 

It will be noted that the leucocytes are all mononuclear. (Eye-piece i. objective 1-8. Bausch and Lomb.) 



MICROSCOPIC EXAMINATION. 257 

Charcot-Leyden crystals (Fig. 68), which are usually absent at 
the beginning of an attack of asthma, at which time only the spirals 
are observed, may be seen to develop from the spirals when these are 
kept for several days. They will be considered later on in studying 
the chemistry of the sputum. 

Echinococcus Membranes. — Echinococcus membranes come from 
a perforating cyst of the liver, kidney, or lung. They constitute 
rather thick, and at the same time tough, pieces of membrane (Fig. 
69) ; occasionally entire sacs are seen, of the color of white porcelain, 
in sections of which it is possible to make out a fibrillated structure. 
The disease is rare in this country. 

Concretions. — Still rarer is the expectoration of concretions which 
have formed in dilated portions of the bronchi or in tubercular cavi- 
ties, or of calcified bronchial glands that have found their way into 
the lungs. Curious examples of the occurrence of such concretions 
have been reported. Andral thus cites a case of phthisis in which 
within eight months as many as 200 stones were expectorated, and 
Portal mentions a case in which 500 were thus expelled. 

Foreign Bodies. — Foreign bodies which have accidentally entered 
the air passages and have remained there for a long time may also be 
found in the sputum. Heyfelder mentions a case in which a man 
coughed up a wooden cigar-holder with pus and blood after eleven 
and a half years. 

Microscopic Examination. 

Under this heading it is necessary to consider leucocytes, red 
blood-corpuscles, epithelial cells, elastic fibres, corpora amylacea, 
parasites, and crystals. 

Leucocytes. — Leucocytes, usually polynuclear in character, are 
found in every sputum in considerable numbers, imbedded in a 
homogeneous, more or less tenacious material. At times they appear 
very granular, containing fat-droplets, or granules of pigment, such 
as carbon or hamiatoidin. Their number varies considerablv, beino: 

%I y O 

naturally greatest in cases of perforating abscess, empyema, putrid 
bronchitis, etc. 

While the leucocytes, which are usually found in the sputum, are 
of the neutrophilic variety, eosinophiles may also be observed, and 
especially in asthmatic sputa, where they often predominate. Free 
eosinophilic granules are then also seen, and I have repeatedly observed 
specimens in which the spirals (see above) were literally covered with 
these granules (Plate XII.). The presence of eosinophilic leucocytes 
is, however, not characteristic of the sputa of bronchial asthma, as 
they may be met with in other diseases as well. Teichmuller has 
recently pointed out that they are present in a large percentage of 
tubercular cases and may be found months before tubercle bacilli 
17 



258 THE SPUTUM. 

can be demonstrated. He regards their occurrence as evidence of a 
defensive struggle on the part of the body, which is most evident in 
fairly strong individuals. In recovery a gradual increase in their 
number is always noticeable, and a diminution, Teichmuller thinks, 
is indicative of a relapse, or, if the diminution occurs rapidly, of 
florid consumption. These statements, however, lack confirmation 
and are probably too dogmatic. 

Basophilic leucocytes have also been observed. 

Red Blood-corpuscles. — The presence of red blood-corpuscles in 
small numbers does not, by any means, indicate serious pulmonary or 
cardiac disease, as they may be found in almost any sputum, and 
especially in that of individuals who smoke much or live in a smoky 
atmosphere ; they are, without doubt, derived from the catarrhally 
inflamed bronchial or tracheal mucosa. Whenever they occur in 
large numbers, however, their presence becomes important. They 
may thus be observed in acute bronchitis, pneumonia, oedema of the 
lungs, bronchiectasis, abscess, gangrene — in fact, in all pulmonary 
diseases. Their occurrence is most important in phthisis, and is, in 
fact, one of the most constant symptoms of the disease. 

The form of the red corpuscles will depend upon the length of 
time that they have remained in the lungs, and all gradations from 
the typical red corpuscle to its shadow, or even fragments, may thus 
be observed. In pneumonia the microscopic examination may at 
times be disappointing, the appearance of the sputum suggesting 
that red corpuscles in large numbers are present, while, as a matter 
of fact, they are almost all destroyed, the color being due to altered 
pigment. It may even be necessary at times to depend upon chem- 
ical methods to clear up any doubt as to the source of the color of 
the sputum. It should always be remembered that the presence of 
blood-pigment is not always indicated by a red color, but that it may 
also assume a golden-yellow or even a greenish tinge, owing to cer- 
tain chemical changes which have taken place. The golden-yellow 
and the grass-green sputa observed in cases of pneumonia during 
convalescence belong to this class. 

Epithelial Cells. — Epithelial cells may also be observed in the 
sputum. While a great deal of information might be expected from 
their presence from a diagnostic point of view, as accurately indi- 
cating the parts of the respiratory tract attacked by disease, the data 
obtained are of little value. 

Cylindrical epithelial cells, providing they do not come from the 
nose, indicate in a general way an inflammatory condition of the 
lower larynx, trachea, or bronchi. They are not of much impor- 
tance, however, as their form is usually so much altered that it is 
often difficult to recognize them ; they may thus become polyhedral, 
cuboidal, or even round, and can then hardly be distinguished from 



MICROSCOPIC EXAMINATION. 



259 



eucocytes. Actively moving cilia can be found only in perfectly 
resh sputa, immediately after being expectorated. If ciliated epi- 
helial cells can be definitely recognized in a sputum, it may be in- 
erred that we are dealing with a pathologic condition of an acute 
nature, providing, of course, they did not come from the nose. 



Fig. 70. 







Epithelium, leucocytes, and crystals of the sputum (eye-piece III., objective 8 A, Eeichert) : 
a, a', a", alveolar epithelium ; b, myeline forms ; c, ciliated epithelium ; d, crystals of calcium car- 
bonate ; e, hsematoidin crystals and masses ; /,/,/, white blood-corpuscles ; g, red blood-corpuscles; 
A, squamous epithelium, (v. Jaksch. ) 



Much importance was formerly attached to the so-called alveolar 
epithelial cells (Fig. 70) as an aid in diagnosis. Buhl thus imagined 
these, particularly when undergoing fatty or myelin degeneration, 
to be absolutely pathognomonic of pulmonary disease, and especially 
of that form of pneumonia which has been termed essential idiopathic 
desquamative pneumonia. Bizzozero, however, as well as others, 
have shown that these cells do not only occur in almost every known 
pulmonary disease, but also in the so-called " normal " expectoration, 
which at times is obtained upon making a very forcible expiration. 

Bizzozero describes these cells as round, oval, or polygonal bodies, 
varying in size from 20 fi to 50 fi. They may contain one, two, or 
three oval nuclei, which are rather small and provided with nucleoli. 
The latter are usually hidden beneath numerous granules. Some of 
these granules are albuminous, but most of them are either pigment 
granules, fatty granules, or myelin granules. The myelin granules 
were first discovered by Virchow in 1854, and termed myelin gran- 
ules on account of their resemblance to mashed nerve-matter. They 
are distinguished from the other forms by their clear, pale, colorless 
appearance and the fact that, at times, fine concentric striatums can be 
detected. These forms may be round, but more often thev are irregu- 
lar. At times fatty, myelin, and pigment granules may be seen in 
oik 1 and the same cell. Possibly they are derived from the pulmo- 
nary alveoli, but this is still an open question. Chemically, the 



260 THE SPUTUM. 

myelin droplets have been shown to contain a considerable amount 
ofprotagon, besides traces of lecithin and cholesterin. 

Liver cells may at times be observed in the sputa in cases of liver- 
abscess, and are easily recognized by their characteristic form. 

Elastic Tissue. — Much more important from a clinical stand- 
point are the elastic fibres and shreds of elastic tissue which may 
be found in sputa. They vary very much in length and breadth and 
are provided with a double, undulating contour ; they are usually 
curled up at their ends. Very often they exhibit an alveolar arrange- 
ment (Fig. 71), which at once determines their origin. 

Fig. 71. 




Elastic fibres in the sputum (eye-piece III., objective 8 A, Reichert). (v. Jaksch.) 

Whenever present, elastic tissue is an absolute indication that a 
destructive process is going on in the lungs. It is found in cases of 
abscess of the lungs, bronchiectasis, occasionally in pneumonia, and, 
most important of all, in phthisis. In gangrene of the lung, elastic 
tissue is usually not found ; this is probably owing to its destruction 
by a ferment, as suggested by Traube. 

In every case it is necessary to determine whether the elastic tissue 
may not be owing to the presence of animal food in the sputum, and 
it may, hence, be stated as a safe rule that it can only be regarded 
as absolutely characteristic when showing the alveolar arrangement. 

In order to demonstrate the presence of elastic tissue in the sputum 
it is necessary to examine large quantities with a moderately low 
power, and best, after the addition of a strong solution of sodium 
hydrate. The sputum may also be boiled with a 10-per-cent. solu- 
tion of the reagent, an equal volume being added ; after dilution with 
four times its own volume of water it is allowed to settle for twenty- 
four hours. The centrifugal machine will here be found of great 
assistance. 



ANIMAL PARASITES. 261 

The following method, in use at the Johns Hopkins Hospital, is 
most convenient : " A small amount of the thick, purulent portion 
of the sputum is pressed out into a thin layer between two pieces of 
plain window-glass, 15 by 15 cm. and 10 by 10 cm. The particles 
of elastic tissue appear on a black background as grayish-yellow 
spots, and can be examined in situ under a low power. Or, the 
upper piece of glass is slid off till the piece of tissue is uncovered, 
when it is picked out and examined on a slide, first with a low and 
then with a higher power. At first there will be some difficulty in 
distinguishing with the naked eye between elastic fibres and parti- 
cles of bread, or milk globules, or collections of epithelium and 
debris, but with practice such mistakes are rarely made, and the mi- 
croscope always reveals the difference." (Musser.) 

Animal Parasites. 

Portions of echinococcus cysts, viz, pieces of membrane (Fig. 70) 
and hooklets (Fig. 72), are occasionally seen, when the parasite has 
lodged in the lungs or in the neighboring organs. The disease, 
however, is exceedingly rare in this country. 

Fig. 72. 



^ 



d*T 






Hooks from taenia echinococcus. X 350. 

The adult parasite (Fig. 73), taenia eehinoGoceus (v. Siebold), is 
found in the intestinal canal of dogs. It measures from 3 to 5 mm. 
in length. If the eggs of the parasite are introduced into the diges- 
tive tract of man, the embryos may make their way into the lungs, 
liver, or other organs, and there give rise to the formation of cysts, 
which are often of enormous size. 

Trichomonades have at times been observed in cases of gangrene 
of the lung, and in the pus removed post-mortem from lung-cavities. 
They arc identical with the trichomonas vaginalis of Donne. Most 
important is the presence of the amce&a eo/i, as the diagnosis o\^ he- 
patic abscess with perforation into the lung may be made in every in- 
stance in which this organism is encountered in the sputa (see Feces). 



262 



THE SPUTUM. 



A certain form of pulmonary disease, closely simulating phthisis, 
is very common in Japan, and has been shown to be referable to the 
presence of a distinct parasite in the lungs, the distoma pulmonale, 
Balz : syn.j distoma "Westermanni (Kerbert), distoma Ringeri (Cob- 
bold). The worm and its ova are found in the sputum. " The 



Fig. 73. 




Human echinococcus. (From Finlayson, after Davaine. ) A, a group of echinococci, still ad- 
hering to the germinal membrane by their pedicles. X 40. B, an echinococcus with head mvag- 
inated in the body. X 107. C, the same compressed, snowing suckers and hooks of the retracted 
head. D, echinococcus with head protruded. E, crown of hooks, showing the two circles. X 350. 

parasite is 8 to 10 mm. long, 5 to 6 mm. wide, of a club shape, 
rounded off very markedly in front, less rounded posteriorly. The 
color during life is almost like that of earth-worms. The two suck- 
ing disks are almost equal in size. The ova are brown, with a thin 
shell, lidded, 0.1 mm. long and 0.05 mm. wide." (Huber.) 

In this country the parasite has been found in the cat and in the 
dog ; in the human being one case at least, occurring in a Japanese 
student, has already been reported. It is interesting to note that 
many Charcot-Leyden crystals are at the same time found in the 
sputum. 

Vegetable Parasites. 

Pathogenic Organisms. — The Tubercle Bacillus. — The most 
important vegetable parasite met with in the sputa is the bacillus of 
tuberculosis. The history of the discovery of this organism, and the 
theories which were held before its pathogenic importance was 
established, cannot be considered here. Suffice it to state that the 
study of bacteriology has given no other discovery of equal impor- 
tance from a clinical point of view. How primitive and wholly 
inadequate were the means formerly employed in making the diagnosis 
of this, the most formidable disease of modern times ! The presence 
or absence of elastic tissue in the sputa was practically all that phy- 
sicians formerly had to guide them beyond the history of the patient 



VEGETABLE PARASITES. 



263 



and the results of a physical examination. The demonstration of 
elastic tissue, however, as has been pointed out, merely indicates the 
existence of a destructive process in the lungs. Under such condi- 
tions it was of necessity impossible to diagnose tubercular disease in 
its incipiency. It is true that cases are occasionally observed in 
which tubercle bacilli are never present in the sputa, and are only 
discovered post mortem. Such cases, however, are extremely rare, 
and do not in the least detract from the importance which attaches 
to careful and repeated examinations of the sputa in all doubtful 
cases. 

From a macroscopic examination it is impossible to decide whether 
or not a particular sputum is of tubercular origin. At times a cer- 
tain sputum may have a suspicious appearance, but it is never 
possible to speak with certainty from simple inspection, as a mucoid 
sputum may contain tubercle bacilli in large numbers, while a muco- 
purulent sputum may be entirely free from them. Reliance should, 
hence, only be placed upon a careful microscopic examination. When 
found their presence is, of course, pathognomonic. A negative result, 
however, does not exclude the existence of tubercular disease. The 
possibility that they may be altogether absent from the sputum has 
been mentioned. In some instances they may be present at times 
and absent at others. In all cases in which the existence of phthisis 
is suspected it is imperative to make use of every device which may 
aid in its detection. In this connection, I wish to strongly insist 
upon the method of " growing the bacilli/' as it were, in the warm 
chamber for from twenty-four to forty-eight hours, and then re- 
examining the sputa in doubtful cases, as Nuttal demonstrated beyond 
a doubt, that the tubercle bacillus will multiply in the sputum itself 
at a certain temperature. The value of this observation is obvious, 
and I have repeatedly been able to demonstrate their presence in this 
manner when it was impossible to detect them in the fresh sputum. 

The centrifugal machine in such cases is also useful and yields 
valuable results, the probabilities of finding the bacilli, when present 
in small number, being very much increased. 

If but few bacilli are present, the following procedure may also 
be employed : About 100 c.c. of sputum are boiled with double the 
amount of water, to which from six to eight drops of a 10-per-cent. 
solution of sodium hydrate have been added, until a homogeneous 
solution has been obtained, water being added from time to time to 
allow for evaporation. This is then centrifugated or set aside for 
twenty-four to forty-eight hours and examined for tubercle bacilli 
and elastic tissue. 

In the examination of tubercular sputa the tine, caseous particles 
described on page 253 should be carefully sought for, as they eon- 
tain the largest number of* bacilli. In their absence reliance should 



264 THE SPUTUM. 

be placed upon the examination of a large number of preparations. 

If, notwithstanding the fact that all due precautions have been 
taken, no bacilli can be demonstrated in the sputum, and the clinical 
history and the physical signs are indefinite or negative, the prob- 
abilities are that we are dealing with a benign process. From an 
examination of the sputa alone, in such cases, it is utterly impossible 
to reach a definite conclusion. When the amount of sputum, more- 
over, is small and contains but little pus, the absence of tubercle 
bacilli, in doubtful cases, is less suggestive of the absence of tuber- 
cular disease than in cases in which the sputum is more abundant and 
mu co-purulent. 

It has been pointed out that the discovery of the etiologic relation 
existing between the bacillus of tuberculosis and tubercular disease, — 
notably phthisis, — must be regarded as one of the most important for 
the clinician, if not the most important in itself, made by bacteri- 
ologists. This is certainly true, but the discovery of certain char- 
acteristics of the tubercle bacillus which are of direct practical utility 
in its recognition and differentiation from other organisms is equally 
important. Reference is had to the behavior of the micro-organism 
toward certain staining reagents and the difference, in this respect, 
which exists between it and other bacteria, and which renders its 
recognition an easy matter. 

Only two bacilli are likely to be mistaken for the tubercle ba- 
cillus, viz, the bacillus of leprosy and the smegma bacillus. All 
three are characterized by the difficulty with which they take up 
basic dyes, and the great tenacity with which these are retained, 
when once stained, upon treatment with mineral acids. 

That confusion should arise in the differentiation between the 
tubercle bacillus and the bacillus of leprosy, is, however, very un- 
likely. More important is the smegma bacillus, which is now known 
to occur, at times, upon the tonsils, the tongue, and in the tartar of 
the teeth of perfectly healthy individuals. In the sputum, coming 
from the lungs, it has been observed by Frankel and Pappenheim, 
and to the latter we are indebted for a method by which we are en- 
abled to accurately differentiate such cases from tuberculosis. This 
is essentially based upon the greater ease and rapidity with which the 
smegma bacillus is decolorized by means of fluorescein-alcohol, as 
compared with the tubercle bacillus. As the other methods which 
have hitherto been in use in the clinical laboratory, do not permit 
of the differentiation between the two organisms, I have given Pap- 
penheim's method the first place, but have retained the others also. 
They may be employed as heretofore, unless special reasons exist for 
eliminating the smegma bacillus, the occurrence of which in the 
sputum must after all be regarded as a medical curiosity. In the 
examination of urinary deposits, however, where the smegma bacil- 



VEGETABLE PARASITES. 26"> 

lus is far more commonly seen, these older methods are not appli- 
cable (see Urine). 

Methods of Staining the Tubercle Bacillus. — 1. Pappexheim's 
Method. — A drop of the sputum, or, if the cheesy particles described 
above, are present, one of these is spread in a thin layer between two 
•cover-glasses. These are then drawn apart, dried in the air, and 
fixed by being passed three times through the flame of a Bunsen 
burner or an alcohol lamp. Larger quantities of the sputum may 
also be employed, and are spread upon slides and examined in the 
same manner, a drop of the immersion oil being placed directly upon 
the dried and stained sputum. The specimens are then covered with 
a few drops of carbol-fuchsin solution and heated to the boiling point. 
The solution is composed of one part of fuchsin, 100 parts of a five- 
per-cent. solution of carbolic acid and 10 parts of absolute alcohol. 
The excess of the staining fluid is drained off, when the preparations 
are immersed from 3 to 5 times in Pappenheim's solution, care being 
taken to let the fluid drain off slowly after each immersion. The 
reagent consists of one part of corallin (rosolic acid) in 100 parts 
of absolute alcohol, to which methylene blue is added to saturation. 
This mixture is further treated with 20 parts of glycerin and is then 
ready for use. The specimens are finally washed in water, dried 
between filter-paper and mounted in balsam, or oil of cedar. A -^ 
oil immersion lens is very convenient, but not a necessity, as the 
organisms are quite readily seen with lower powers, such as Zeiss' 
DD, Leitz' 7, or Bausch and Lomb's J or J, with a correspondingly 
high eyepiece. 

2. Gabett's Method. — The dried preparations are floated for 
two minutes upon the carbolic-fuchsin solution described above, and 
are immediately transferred, without washing, to a solution com- 
posed of two parts of methylene blue in 100 parts of a 25-per-cent. 
solution of sulphuric acid, where they remain one minute. They are 
then washed in water and mounted. 

This method of staining is very convenient and the one most gen- 
erally employed. The smegma bacillus, however, is also stained. 

3. The Weigert-Ehrlich Method. — Dried specimens are 
prepared, and stained for twenty-four hours with a solution of fuch- 
sin in anilin-water, by floating upon the surface. The staining 
fluid is prepared as follows : 

A small test-tube full of water is shaken with about twenty drops of 
pure anilin oil (1 : 20 ), and after standing for a few minutes, filtered 
through a. moistened filter. To this solution a lew drops oi' a con- 
centrated alcoholic solution of fuchsin or of methyl-violet are added, 
until the mixture becomes slightly cloudy — ; . c, until a metallic 
lustre is noted on the surface. After twenty-four hours the prepa- 
rations are washed with water in order to remove an excess o^ the 



266 THE SPUTUM. 

staining fluid. They are then immersed for several seconds in a 
dilute solution of nitric or hydrochloric acid (1 : 6, 1 : 3, or 1 : 2), 
and washed again with water or with absolute alcohol. At this time 
the specimens should have a faintly red or violet color. They are 
then dried between layers of filter-paper or in the air, and mounted 
as usual. 

If it is desired to use a counter-stain, Bismarck-brown, vesuvin, 
or methylene blue in watery solutions may be used for the purpose. 
Into this solution the specimen is placed after treatment with nitric 
acid and washing in water. It remains for about two minutes, and 
is then washed, dried and mounted, as above. 

4. Ziehl-Neelsen's Method. — A mixture of 90 parts of a 5- 
per-cent. solution of carbolic acid and 10 parts of a concentrated 
alcoholic solution of fuchsin is used. The procedure is the same 
as that described under the Weigert-Ehrlich method. With both 
methods, however, it is unnecessary to stain the preparation for 
twenty-four hours, unless special accuracy is required, and, as a rule, 
it is sufficient to place a few drops of the staining fluid upon the 
cover-glass and to boil this for a few seconds over the free flame, 
when the specimen is further treated as described. In this manner 
excellent results may be obtained in a few minutes. 

Stained according to one of these methods, the bacilli appear as 
rods measuring about 3 fi to 4 p. in length by 0.3 fi to 0.5 // in 
breadth (Plate XIII., Fig. 1). Usually they are not swollen at 
their extremities, but simply rounded off. They occur as homogeneous 
rods or may present within their stained bodies small round or ovoid 
granules, placed end to end, which do not stain. They may also 
have a straight or a curved form, or the bacillus may appear to be 
doubled upon itself in the form of the letter S. The small, hyaline 
bodies in the bacilli have been regarded as spores. 

The number of bacilli which may be found in a sputum varies 
greatly, and while in general it may be said that it is in direct ratio 
to the intensity of the disease, and may thus be considered as of 
some prognostic value, too much reliance should not be placed upon 
this statement, as in acute miliary tuberculosis, and in cases that 
have gone on to the formation of cavities, the number may be very 
small or they may be altogether absent. In an incipient case, on the 
other hand, in a little mucoid sputum, the number may be very large. 

Of the variations in number and form of the tubercle bacilli dur- 
ing the treatment with Koch's tuberculin it is unnecessary to speak 
at this place, as the prognostic significance attaching to such varia- 
tions is as yet but imperfectly understood. 

The Diplococcus Pxeumoni.e. — In doubtful cases the sputum 
may be examined for the diplococcus pneumonia?, and it may be ac- 
cepted at the present time that its presence in a given case, provid- 



plate xrn 



i £ 



<y 



si »«",V; 



// 



<& 



Tuberculous Sputum Stained by Gabbett's Method. The Tubercle Baeill 
are seen as Red Rods, all else is Stained Blue. (Abbott.) 




The Diploeoeeus Pneumoniae, Stained with Methylene Blue and Fuehsin 

as a Counterstain. Taken from the Sputum of a Case of 

Acute Croupous Pneumonia. 

FIG. 3. 



(•• 



a 

.» 



iS ^ 









A 



... * 



Heart- Disease Cells, showing Mveolar Epithelial Cells, I .oaded Down 
with Granules of Hsematin. 



VEGETABLE PARASITES. 



267 



ing that the clinical history and the physical signs point to a pneu- 
monia, renders the diagnosis of acute croupous pneumonia very 
probable. 

Method : Cover-glass specimens, prepared as indicated above, are 
placed for one or two minutes in a 1-per-cent. solution of acetic acid ; 
they are then removed, the excess of acetic acid drawn off by means 
of a pipette, when they are allowed to dry in the air and subsequently 
placed for several seconds in saturated anilin-water and gentian- 
violet solution, washed in water and examined. Rod-shaped diplo- 
cocci (Plate XIII., Fig. 2), surrounded by a capsule, which latter is 
considered as the characteristic feature of this organism, will be seen 
in cases of acute croupous pneumonia. 

The bacillus of influenza has already been considered in Chapter 
I. (p. 108). In the sputum it is frequently associated with pyogenic 
cocci and pneumococci. 

Fig. 74. 





Actinomyces. (Musser. ) 

In whooping-cough protozoa have been observed by Deichler and 
Kurloff; their observations have not as yet been confirmed, however, 
and other observers attribute the disease to the presence of bacteria. 
Among these may be mentioned Affanasiew, Ritter, Czaplewski. 
Hensel, Koplik, and others. All these investigators claim to have 
isolated a micro-organism from the sputum of whooping-cough, which 
they regard as the cause of the disease. Whether or not Affanasiew's 
bacillus is identical with Hitter's diplococcus and with the pol-bacillus 
of Czaplewski, Hensel, and Koplik is, however, not clear. Koplik 3 s 
organism is extremely minute, measuring from 0.8-1.7 it in length, by 
0.3-0.4 (i in breadth. When stained with Lotfier's blue it has a finely 
punctate appearance, like the diphtheritic bacillus. In pure culture 
it is not decolorized by drain's method. It is anaerobic as well as 
aerobic, and apparently not motile. To isolate it from the sputum 



268 THE SPUTUM. 

it is best to obtain some of the grayish-white pellets, which are ex- 
pectorated during the convulsive stage. In these, small particles 
will be seen, resembling scales of dandruff. Such particles are 
isolated and planted first on hydrocele fluid, in order to obtain the 
crude culture. Later it may be grown in bouillon, on agar, gelatin, 
etc. On Lomer's serum a whitish growth is obtained, which closely 
simulates that of the diphtheria bacillus. 

Actinomycosis of the lungs may at times be diagnosed from the 
presence of the characteristic granules and thread-like formations in 
the sputum. In America the disease is very rare. 

The organism in question (Fig. 74) probably belongs to the species 
cladothrix, occupying a unique position among the pathogenic bac- 
teria. Infection in man and animals (cattle and pigs) possibly occurs 
through ears of barley or rye, a supposition, with which the observa- 
tion that the disease frequently begins in the autumnal months 
accords. 

In the pus derived from ulcerating actinomycotic tumors, in the 
sputum in cases of pulmonary actinomycosis, as also in the feces, 
when the disease has attacked the intestines, small yellow granules 
will be observed, measuring from 0.5 to 2 mm. in diameter. If 
such a granule is examined microscopically, slight pressure being 
applied to the cover-glass, it will be seen to consist of numerous 
threads, which radiate out from a centre in a fan-like manner, and 
present club-shaped extremities. 

The organism may be demonstrated in the following manner : 
Dried cover-glass preparations are stained for five to ten minutes 
with a saturated anilin-water and gentian-violet mixture (see p. 
129), w T hen they are rinsed in normal salt-solution, dried between 
filter-paper, and transferred for two or three minutes to a solution of 
iodo-potassic iodide (1 or 2 : 100). They are then again dried be- 
tween layers of filter paper, decolorized in xylol-anilin oil (1 : 2), 
washed in xylol, and mounted in balsam. The mycelium assumes a 
dark-blue color. 

Non-pathogenic Organisms. — Of the non-pathogenic micro-organ- 
isms which may be observed in sputa but little is known. 

Oidium albicans may be seen in children, and is usually derived 
from the mouth. 

Of other fungi which are occasionally observed there may be 
mentioned the aspergillus fumigatus and mucor corymbifer. Sac- 
charomyces has been seen in the pus derived from pulmonary ab- 
scesses. Sarcina pulmonalis has been found at times, and especially 
in the so-called mycotic bronchial props occurring in putrid bron- 
chitis. They are usually smaller than the sarcina? ventriculi, but 
larger than the sarcina? observed in the urine ; they present the 
characteristic form of the latter. Various other bacilli and micro- 



VEGETABLE PARASITES. 269 

cocci, in addition to those mentioned, are also found in the sputa in 
large numbers, but have not as yet been closely studied, excepting 
the pus-organisms, which may be almost always demonstrated. 

Crystals. — Of crystals which may occur in sputa, it will be neces- 
sary to briefly consider the crystals of Charcot-Leyden, haematoidin, 
cholesterin, margarin, tyrosin, oxalate of calcium, and triple phos- 
phates. 

Charcot-Leyden crystals (Fig. 68) were discovered in the sputa 
of patients suffering from asthma, and were supposed to stand in a 
causative relation to the disease. While the crystals are usually 
present in this disease, they are also exceptionally met with in acute 
and chronic bronchitis, phthisis pulmonalis, etc. 

Chemically, they appear to be phosphate of spermin, which has 
the composition C 2 H 5 N, and has been shown to be identical with 
ethylenimin. The phosphate crystallizes in the form of colorless, 
elongated octahedra, which vary very much in size, specimens being 
at times met with measuring from 40 tt to 60 [x in length. It is 
soluble with difficulty in cold water, insoluble in alcohol, ether, 
chloroform, and dilute saline solution and slowly soluble in acids and 
alkalies and even in ammonia. Its chemical composition and the 
fact that the same crystals are found in decomposing viscera, at 
times forming a complete covering of old anatomical preparations, 
render the supposition very probable that the substance in question 
is closely related to the ptomains ; the occurrence of the crystals 
may, indeed, be regarded as indicating a retrogressive metamorpho- 
sis of the cellular elements of a part. They are found not only in 
the sputa, in the diseases mentioned, but also in leukemic blood, in 
the mucus which has accumulated in a dilated biliary duct, and in 
normal and leukemic bone-marrow. As has been stated, the crys- 
tals are also quite constantly met with in the feces in ankylostomia- 
sis, anguilluliasis, and other helminthiases (see p. 196). Bizzozero 
found them in his own sputum, at times, when suffering from a simple 
acute bronchitis. 

Hcematoidin crystals may be observed in the sputa following ex- 
travasations of blood into the lung. They frequently occur in the 
form of ruby-red columns or needles (Plate I., Fig. 2) ; amorphous 
granules, however, are also seen, enclosed in the bodies of leucocytes, 
in which case they are probably always indicative of a previous 
hemorrhage, while the needles are generally observed when an ab- 
scess or empyema has perforated into the lungs. Chemically, hsema- 
toidin is derived from blood pigment, and appears to bo closely re- 
lated to bilirubin (see p. 42). 

Cholesterin crystals are at times seen in the sputa, in cases ot' phthi- 
sis, pulmonary abscess, and in general, whenever old accumulations 
of pus have entered the lung from a neighboring organ. They are 



270 THE SPUTUM. 

readily recognized by their characteristic form and chemical proper- 
ties (see Feces, p. 214). 

Fatty-acid crystals are frequently observed in cases of putrid bron- 
chitis and gangrene of the lung, and -also in cases of bronchiectasis 
and phthisis. They occur in the form of single needles or groups 
of needles, which are long and pointed. They are easily soluble in 
ether and hot alcohol ; insoluble in water and acids. Chemically, 
they are probably composed of the higher fatty acids, such as pal- 
mitic and stearic acid. 

Tyrosin crystals have been observed in cases of putrid bronchitis, 
perforating empyema, etc. Leucin is likewise probably always pres- 
ent, occurring in the form of highly refractive globules. For the 
recognition of these bodies, particularly of tyrosin, a chemical exam- 
ination should always be made, as crystals of the soaps of fatty acids 
have frequently been mistaken for those of tyrosin (see Urine). 

Oxalate of calcium crystals are rarely seen. Fiirbringer observed 
them in large numbers in a case of diabetes, and Unger found them 
in a case of asthma. They are readily recognized by their envelope- 
form, but they also occur in amorphous masses. They are soluble 
in mineral acids, insoluble in water, alkalies, organic acids, alcohol, 
and ether. 

Triple phosphate crystals are also, though very rarely, seen, as in 
cases of perforating abscesses, etc. They are recognized by their 
coffin-lid shape and the readiness with which they dissolve in acetic 
acid. 

Chemistry of the Sputum. 

In addition to the substances described, sputum contains certain 
albumins, volatile fatty acids, glycogen, ferments, and various inor- 
ganic salts. 

Among the albumins which have been observed in sputa may be 
mentioned serum-albumin, and especially mucin, which is often pres- 
ent in large amounts. In pneumonic and purulent sputa peptone 
also has been found. 

In order to demonstrate the presence of serum-albumin the sputa 
are treated with dilute acetic acid, when the filtrate is tested with 
potassium ferrocyanide, as described in the chapter on Urine. 
Serum-albumin is, of course, found in notable quantities in cases of 
oedema of the lungs. 

The volatile fatty acids contained in sputa may be obtained by 
diluting with water, acidifying with phosphoric acid, and distilling, 
when the distillate is further examined as described in the chapter 
on Feces. Acetic, butyric, propionic, and capronic acid have been 
found. 

The fats and fixed fattv acids are extracted from the residue with 



THE SPUTA IN VARIOUS DISEASES 271 

ether, and shaken with a solution of sodium carbonate in order to 
transform them into their sodium salts, when the ether is decanted 
and evaporated, leaving the fats behind. 

Glycogen has been repeatedly demonstrated in sputa and may be 
detected by Ehrlich\s method (see page 48). 

The sputa of gangrene of the lung and putrid bronchitis have been 
shown to contain a ferment resembling trypsin. In order to test for 
this ferment the sputa are extracted with glycerine ; the examination 
is then continued as described in the chapter on the Examination of 
Cystic Contents. 

The myelin granules, as I have already indicated, largely consist of 
protagon, lecithin, and cholesterin. 

The following are the inorganic salts which may be demonstrated 
in the sputum : The chlorides of sodium and magnesium, phosphates 
of the alkalies and the alkaline earths, viz, calcium and magnesium, 
the sulphates of calcium and sodium, carbonates, phosphate of iron, 
and silicates. 

The Sputa in Various Diseases. 

Acute Bronchitis. — In the beginning of the disease the expectora- 
tion is small in amount, transparent, and contains very few cellular 
elements, constituting the so-called sputum crudum of the ancients. 
Microscopically there is evidence of the existence of a desquamative 
process extending toward the pulmonary alveoli to a greater or less 
extent, and especially implicating the bronchi and trachea. Epithelial 
cells of various forms are found, and are probably derived from cells 
which were originally ciliated. Ciliated cells may occasionally be ob- 
served in perfectly fresh specimens, but are usually absent. Leucocytes 
in small numbers and alveolar cells are also seen. The presence of a 
few red blood-corpuscles is a common occurrence, and probably due 
to rupture of a capillary blood-vessel. Later on the sputa become 
more abundant, opaque, and assume a yellow color tending to green, 
owing to an increase in the number of leucocytes, while the other 
cellular elements diminish in number. 

Chronic Bronchitis. — The amount and consistence of the sputum 
in this condition varies greatly ; it is most abundant in cases of so- 
called bronchorrhoea, in which whole mouthfuls may be expectorated 
at a time. The color is usually a yellowish-green, owing to the 
presence of numerous pus-corpuscles in various stages of degenera- 
tion. Microscopically enormous numbers of micro-organisms aiv 
found, especially in cases in which the sputa have remained for some 
length of time in the bronchi. In addition, some red corpuscles and 
epithelial cells arc found ; the latter, however, arc not so abundant 
as in the first stage of an acute bronchitis. A few alveolar epithelial 
cells in a state of fatty and myelin degeneration will also be seen. 



272 THE SPUTUM. 

Putrid Bronchitis and Pulmonary Gangrene. — The sputa of 
putrid bronchitis and pulmonary gangrene resemble each other so 
closely that it is only possible to distinguish between the two by the 
presence of debris of pulmonary parenchyma in the latter disease. 
In pulmonary gangrene an exquisite sedimentation is also quite com- 
monly observed when the sputum is placed in a conical glass ; the 
bottom layer is then of a greenish-yellow or brownish color, and con- 
tains a large amount of pus and small greenish or brownish masses, 
which vary in size from that of a millet-seed to that of a bean. 
Fragments of lung-tissue are also quite frequently seen. Micro- 
scopically more or less degenerated leucocytes, crystals of ammonio- 
magnesium phosphate, and perhaps also of tyrosin and leucin, as well 
as hsematoidin, are found. The greenish or brownish material re- 
ferred to contains amorphous masses of pigment, probably derived 
from hsemoglobin, at times elastic tissue, fatty-acid crystals, fat 
droplets and innumerable micro-organisms. Among these the 
leptothrix pulmonaMs is quite conspicuous, and may be recognized by 
the violet or bluish color which it assumes when treated withLugoFs 
solution. Most important in the differential diagnosis between pul- 
monary gangrene and putrid bronchitis is the occurrence of elastic 
fibres arranged in an alveolar manner. The middle layer is whitish, 
transparent, and contains flakes of mucus in suspension. The super- 
ficial layer is frothy and of a dirty greenish-yellow color, the entire 
mass emitting an odor never to be forgotten. 

Fibrinous Bronchitis presents all the characteristics of an ordi- 
nary chronic bronchitis ; the sputa, however, contain in addition 
well-defined fibrinous casts, which have been described (see p. 254). 

Bronchial Asthma. — In this aifectiou, and especially at the com- 
mencement of an attack, the expectoration is scanty, frothy, and 
grayish, or at times rose-colored, owing to an admixture of blood. 
Most characteristic are plug-like masses of a greenish yellow or 
grayish color, containing spirals of Curschmann, Charcot-Leyden 
crystals and a large number of eosinophilic and some basophilic 
leucocytes. 

Pulmonary Abscess. — The sputum, as long as it is fresh, does 
not emit a fetid odor, thus differing from that observed in cases of 
gangrene of the lung. It consists almost entirely of pus ; elastic 
fibres are present in abundance, as also brownish or yellow pigment- 
ing niatoidin. Fragments of lung-tissue, enclosed in a mass of pus, 
have at times been observed, together with fatty acids and cholesterin 
crystals. 

Abscess of the Liver with Perforation into the Lung. — The 
sputa are of a reddish -yellow or reddish-brown color, viscid, muco- 
purulent, and are frequently discharged in large amounts. Micro- 
scopically, pus-corpuscles, red blood-corpuscles, pigmented alveolar 



THE SPUTA IN VARIOUS DISEASES. 273 

cells, often undergoing fatty degeneration, as well as elastic tissue 
and granular detritus, are found. The presence of actively moving 
amoebae is, of course, most important from a diagnostic point of view, 
and absolutely pathognomonic. Liver-cells, pieces of echinococcus- 
membranes, and hooklets may be observed in other cases. 

Pneumonia. — During the first and third stage a simple catarrhal 
sputum is observed which does not offer any special characteristics. 
During the second stage, however — i. e., that of hepatization — the 
sputum is usually quite characteristic. Its color is then reddish- 
brown — the classical rust-colored expectoration. The sputum at the 
same time is generally so tenacious that the spit-cup can actually be 
inverted without loosing a drop of its contents. Microscopically the 
following elements may be found : red corpuscles (to the presence 
of these the reddish color is principally due) ; at times, however, 
only a small number is observed, when the color is referable to 
haemoglobin which has been dissolved out from the corpuscles, and 
in such cases but few, if any, corpuscles are found. Leucocytes are 
always present in considerable numbers. Fibrinous casts of the 
finer bronchioles may also be seen, and may, in fact, be visible with 
the naked eye. Alveolar epithelial cells, often loaded with granules 
of pigment, fat, and myelin, as well as others, derived from the 
larger bronchi and the trachea, are seen. Should abscess of the lung 
or gangrene complicate the case, the elements described above under 
these headings will be found in addition, the presence of elastic tis- 
sue being, of course, the most important. 

Note may be taken at the same time of the occurrence of pneu- 
mococci, bearing in mind, however, that their presence is not abso- 
lutely pathognomonic. In doubtful cases, as indicated, their pres- 
ence may be regarded as pointing to croupous pneumonia, providing 
that the clinical history and the physical signs are in accord. 

Phthisis Pulmonalis. — The appearance of the sputum in phthisis 
offers nothing that is characteristic, depending wholly upon the stage 
of the disease, its extent, the existence of complications, etc. In a 
general way it may be said that the sputa in incipient cases are usually 
small in amount, of a grayish-yellow color, and tenacious, the 
amount increasing gradually as the disease progresses, the largest 
quantities at this stage being expectorated in the morning, upon 
rising. When well advanced the nummular sputa are seen. The 
macroscopic examination of the sputa of tubercular patients offers no 
characteristic features, the elements found being practically the same 
as those observed in cases of simple chronic bronchitis, with one ex- 
ception — i. e., the occasional admixture of blood, which is usually 
visible with the naked eye, but may vary greatly in amount. On the 
one hand, small specks or streaks of blood may be thus observed, 
while, on the other, the sputa may consist almost entirely of blood. 
18 



274 THE SPUTUM. 

The color of the sputum is, of course, largely influenced by the 
amount of blood present and the length of time that this has re- 
mained in the lungs, varying from a bright red to a dirty brown. 
In cases in which a considerable hemorrhage has taken place, it is, 
of course, necessary to exclude every other source, before attributing 
the hemorrhage to a pulmonary origin, and in cases of rupture of an 
aneurism, or long-continued hypersemic conditions of the lungs, so 
frequently observed in cases of heart-disease, in hemorrhage of gastric 
origin, and in hemorrhage from the mouth or pharynx, it may at 
times be difficult to determine the source of the blood. 

The diagnosis of phthisis is thus altogether dependent upon a 
microscopic examination, and, above all, upon the demonstration of 
tubercle bacilli and elastic tissue, which have both been considered 
in detail. In addition leucocytes, alveolar epithelial cells, hsenia- 
toidin-crystals, and granules are met with, which latter may be 
present in large numbers, if a hemorrhage has occurred some time 
before. If the process has gone on to the formation of cavities, 
various constituents are also observed which are found, when putre- 
factive processes take place in the lung. 

(Edema of the Lungs. — The sputa here are abundant, thin, 
liquid, and frothy, the color of the foam varying from white to a 
dirty reddish-brown. Chemically such sputa consist almost entirely 
of transuded serum, and are hence particularly rich in serum-albu- 
min. Microscopically, only a small number of leucocytes and a 
variable number of red blood-corpuscles are found, the number of 
the latter, however, being scarcely large enough to account for the 
red color, which v. Jaksch ascribes to the presence of methsemo- 
globin. 

Heart-disease. — The sputa observed in chronic bronchitis, the 
result of chronic heart-disease are characterized by the presence of 
so-called " heart-disease cells " — i. e. f alveolar epithelial cells con- 
taining numerous haematoidin-granules (Plate XIII., Fig. 3). If, 
in consequence of the existence of chronic heart-disease, hemorrhagic 
infarcts have occurred in the lungs, the patient may at times expec- 
torate numerous masses presenting a markedly red color, while later 
on — i. e. f after several days — these masses assume a brownish-red 
appearance, the sputum then presenting the characteristics noted 
some time after a hemorrhage. 

The Pneumoconioses. — Among the pneumoconioses, anthracosis, 
siderosis, chalicosis, and stycosis may be briefly considered. These 
conditions are interesting not only from a physiologic, but also from 
a pathologic standpoint. 

Axtheacosis. — To some extent particles of carbon may be found 
in the sputum of almost every individual, and especially in smokers. 
The sputum in such cases is of a pearl-gray color, and is expecto- 



THE SPUTA IN VARIOUS DISEASES. 275 

rated in larger or smaller masses, especially in the morning upon ris- 
ing. Larger amounts are noted in miners and those who are brought 
into close contact with coal-dust. Microscopically particles of carbon 
and epithelial cells, especially of the alveolar type, as well as leuco- 
cytes, loaded with the pigment, are seen. 

Siderosis. — In siderosis the sputum presents a brownish-black 
color and contains cells enclosing particles of the oxide of iron. 
These may be readily recognized by treating the preparation with a 
drop of ammonium sulphide or potassium ferrocyanide solution in the 
presence of hydrochloric acid, when a black color on the'one hand or 
a blue color on the other is obtained in the presence of iron. 

Chalicosis. — In chalicosis silicates are found in the sputa. 

Stycosis. — This condition was described for the first time by A. 
Robin in a man, aged seventy, who from his seventeenth year suf- 
fered from cough and frequent attacks of diarrhoea, and whose condi- 
tion had been diagnosed as phthisis pulmonalis et intestinarum, at 
various times, although tubercle bacilli could not be demonstrated. 
The patient died from acute pericarditis, complicating an attack of 
acute mono-articular rheumatism. Post mortem the lungs were 
found to be perfectly normal ; the bronchial and anterior mediastinal 
glands, as well as the mesenteric glands, however, were completely 
solidified and composed almost wholly of calcium sulphate. The 
man, it was then found, had been working in plaster-of-Paris all his 
life, and the symptoms observed — viz, cough, expectoration, and diar- 
rhoea — Robin is inclined to attribute to the pressure of the solidified 
glands upon the bronchi and intestines. 



CHAPTER VII. 
THE URINE. 

GENERAL CONSIDERATIONS. 

This is not the place to enter into a discussion of the various 
hypotheses which have been advanced to explain the manner in 
which waste-material is removed from the body through the kidneys. 
It will suffice to state that, while the water and mineral constituents 
of the urine undoubtedly pass into the uriniferous tubules by a process 
of transudation, a selective glandular activity of the cells lining the 
convoluted tubules and the loop of Henle, at least, appears to be 
necessary for the elimination of the most important organic con- 
stituents. 

As the physical characteristics of the urine, as well as its chem- 
ical composition, are influenced not only by the age and sex of the 
individual, but also by the character of the food ingested, the process 
of digestion, exercise, climate, temperature, race, etc., it is apparent 
that a quantitative analysis of any one urine, or even average figures, 
can only give an approximate idea of its composition. The reader 
is referred for information to the special paragraphs concerning the 
variations in the individual constituents observed in health. It is 
important, however, to note that, notwithstanding the fairly wide 
variations here observed, the composition of the blood, as already 
pointed out in a previous chapter, remains quite constant, showing 
the perfect manner in which the nervous system through the kidneys 
guards against an undue accumulation of what may be termed normal 
waste-products in the blood, and in virtue of which abnormal sub- 
stances are also immediately eliminated. Moreover, as will be 
pointed out later on, a perfect mechanism appears to exist which 
prevents an undue accumulation of material in the blood that can 
hardly be regarded as waste. The presence of an amount of sugar 
in the blood exceeding 6 p. m., for example, appears to be invariably 
followed by glycosuria, and the introduction of excessive quantities 
of sodium chloride similarly and almost immediately leads to an 
elimination of the excess. 

276 



GENERAL CHARACTERISTICS OF THE URINE. 277 

GENERAL CHARACTERISTICS OF THE URINE. 

General Appearance. 

Normal urine, just voided at an ordinary temperature, is either 
perfectly clear or but faintly cloudy, owing to the fact that the acid 
and normal salts present are all soluble in water. It may be stated, 
as a general rule, that whenever a urine freshly passed manifests a 
distinct cloudiness some abnormality must exist. 

When allowed to stand for a time a light cloud is seen to develop, 
which gradually settles to the bottom, constituting the so-called 
nubecula of the ancients. Examined under the microscope this is 
found to contain a few round, granular cells, somewhat larger than 
normal leucocytes, the so-called mucous corpuscles, and a few pave- 
ment-epithelial cells, derived from the bladder or genital organs. 
Chemically the nubecula probably consists of traces of mucus. 

When kept for twenty-four hours at an ordinary temperature 
some crystals of uric acid are frequently observed in addition to the 
above elements, usually presenting the so-called whetstone-form. 
If, however, the temperature at which the urine is kept approaches 
the freezing point, the entire volume becomes cloudy, owing to a 
precipitation of acid urates. As these are very much less soluble 
in cold than in warm water, they gradually settle to the bottom of 
the vessel, forming what is known as a sediment, while the super- 
natant fluid again becomes clear. 

If kept still longer, exposed to the air, at the temperature of the 
room, the entire volume of urine again becomes cloudy, owing to a 
diminution of its normal acidity, the result being a precipitation of 
ammonio-magnesium phosphate, calcium phosphate, and still later, 
when the urine has become alkaline, of ammonium urate. 

Gradually a heavy sediment, containing these salts, in addition to 
the constituents of the primitive nubecula, forms at the bottom of 
the vessel ; the supernatant fluid, however, remains cloudy. On 
microscopic examination it will be seen that this cloudiness is due 
to the presence of enormous numbers of bacteria. 

The changes which take place in a normal urine, when allowed 
to stand at an ordinary temperature, may thus be tabulated as 
follows : 

I. Urine clear, no sediment — reaction acid. 
II. Urine slightly cloudy, owing to the development of the 
nubecula — reaction acid. 

AT , i !' Mucous corpuscles, 
iNubeeula -n -,, , •,, r , ,, 

( ravement-epitnelial cells. 

III. Urine clear, the nubecula has settled — reaction acid. 



278 THE URINE. 



{Mucous corpuscles, 
Epithelial cells, 
Uric-acid crystals, 
A few bacteria. 



IV. Urine cloudy, owing to the precipitation of phosphates — 
reaction faintly acid. 

V. Urine cloudy, owing to the presence of bacteria — reaction 
alkaline. 



Sediment 



Bacteria, 

Mucous corpuscles, 
Epithelial cells, 
Triple phosphates, 
Tri-calcium phosphate, 
Ammonium urate. 



Color. 



The color of normal urine may vary from a very light yellow to 
a brownish-red, the particular shade depending essentially upon the 
specific gravity, becoming lighter with a diminishing, and darker 
with an increasing density. Pathologically the same rule holds 
good, except in diabetes in which a very high specific gravity is gen- 
erally associated with a very light color. The reaction of the urine 
also exerts a marked influence upon its color, an acid urine being 
more highly colored than an alkaline urine, which can be readily 
demonstrated by allowing a specimen of acid urine to become alka- 
line, and by treating an alkaline urine with dilute hydrochloric or 
acetic acid. At the same time it may be said that every urine darkens 
slightly on standing, the reaction remaining acid. 

The various shades observed in normal urines may be grouped 
under the following headings : 

1. Pale urines vary from a faint yellow to a straw-color. 

2. Normally colored urines are of a golden or of an amber-yellow. 

3. Highly colored urines present a reddish-yellow to a red color. 

4. Dark urines vary between brownish- red and reddish-brown. 
As these shades may occur in both normal and pathologic urines, 

definite conclusions cannot, as a rule, be drawn from mere inspection. 
A very pale urine simply indicates an excess of water, which may be 
normal, but may also occur in such diseases as chronic interstitial 
nephritis, diabetes mellitus, diabetes insipidus, hysteria, and the 
various anaemias ; it is further seen during convalescence from acute 
febrile diseases, while a highly colored urine, though also occurring in 
health, may indicate the existence of some febrile process. It may be 
stated, as a general rule, that a pale urine always excludes the exist- 
ence of a febrile disease of any severity, and that the continued secre- 



GENERAL CHARACTERISTICS OF THE URINE. 219 

tion of a very pale urine is usually associated with a certain degree 
of anaemia. 

The normal color of the urine is probably owing to the presence of 
several pigments, which are most likely closely related to each other 
and to hseniatin. 

In addition to these colors others may be observed at times, which 
are either pathologic or accidental — i. e., due to the presence of cer- 
tain drugs. The former are, on the whole, of greater importance to 
the physician than those mentioned above, as more definite conclu- 
sions can be drawn from their presence. 

Most important among such pathologic pigments are those due : 

1. To the presence of blood coloring matter. The color in such 
cases may vary from a bright carmin to a jet-black, the exact shade 
depending upon the quantity of blood coloring-matter present, upon 
changes that the blood may have undergone, either before or after 
being passed, and also upon the presence of the pigment in solution 
or contained in red corpuscles. 

2. Those due to the presence of biliary coloring matter. The color 
here varies from a greenish-yellow to a greenish-brown. 

3. A milky-colored urine is observed in cases of chyluria. 
Among the accidental abnormalities in color, on the other hand, 

are those due to the presence of substances like carbolic acid and its 
congeners, santonin, etc. 

As the recognition of the causes of such alterations, normal, patho- 
logic, and accidental, largely depends upon a more detailed study of 
the individual pigments, this subject will be dealt with more fully 
further on (see Pigments and Chromogens). 

Odor. 

The odor of the urine is usually of little significance. Normally 
it resembles that of bouillon, and in some cases that of oysters ; it 
is probably due to the presence of several volatile acids. The odor 
of urines undergoing decomposition is characteristic and has been 
termed " the urinous odor of urine," an ill-chosen term, as this odor 
is always indicative of an abnormal condition. 

The ingestion of asparagus, onions, oil of turpentine, etc., pro- 
duces a characteristic odor which is of no significance. 

Consistence. 

Urine, while normally fluid and but slightly viscid, may in dis- 
ease acquire a marked degree of viscidity, which becomes especially 
apparent upon attempting its filtration ; the liquid passes through 
the paper with more and more difficulty, and finally clogs its pores 
altogether. 



280 THE UEiyE. 

Quantity. 

The normal quantity of the urine is subject to great variation, the 
amount eliminated in the twenty-four hours being influenced by the 
amount of fluid ingested, the nature and quantity of the food, the 
process of digestion, the blood-pressure, the surrounding tempera- 
ture, sleep, exercise, body- weight, sex, age, etc. 

It is easy to understand, then, why the figures given by different 
observers in different countries should vary considerably. Salkow- 
sky, in Germany, thus gives 1,500 to 1,700 c.c. as the normal 
amount; v. Jaksch, in Austria, 1,500 to 2,000 c.c; Landois and 
Sterling, in England, 1,000 to 1,500 c.c. ; Gautier, in France, 1,250 
to 1,300 c.c. In this countrv I have found an average secretion of 
from 1,000 to 1,200 c.c. in the adult male, and 900 to 1,000 c.c. in 
the adult female. It is thus seen that the secretion of urine is 
greatest in Germany and Austria, w r here the body-weight and inges- 
tion of liquids are greater than in England, France, and the United 
States. 

Children pass less, but relatively more urine, considering their 
body- weight, than adults. 

The female passes somewhat less than the male. 

During the summer months, when a larger proportion of water is 
removed from the body through the skin and lungs than in cold 
weather, less urine is voided. The same occurs during repose, 
more urine being passed during active exercise, and hence less dur- 
ing the night than daring the day. 

The amount of urine secreted in the different hours of the day 
varies greatly, reaching its maximum a few hours after meals. It 
decreases toward night, and reaches its lowest point in the first hours 
of the night, after which it begins to rise rapidly until 2 or 3 
o'clock in the morning. 

The ingestion of large amounts of liquid, of course, increases the 
daily amount considerably, and 3,000 c.c. may be passed under such 
conditions by an individual in good health, while it may decrease to 
800 or 900 c.c. when but little liquid is taken. 

After the ingestion of much solid food the secretion of urine is 
temporarily diminished. 

Water containing no salts possesses distinct diuretic properties, as 
do also beer, wine, coffee, tea, etc. 

The most important medical diuretics are digitalis, squill, broom, 
spirits of nitrous ether, juniper, urea, etc. 

Pathologically the amount of urine varies Avithin very wide limits. 
It may be exceedingly difficult, however, to determine in a given 
case, whether or not the secretion is within physiologic limits. As 
a general rule, whenever less than 500 c.c. or more than 3,000 c.c. 
are passed some abnormal condition exists, providing all other causes 



GENERAL CHARACTERISTICS OF THE URINE. 281 

which might lead to the secretion of such an amount can be elimi- 
nated. 

Clinically we speak of polyuria and oliguria. 

Polyuria. — Polyuria has been observed in many different diseases, 
and under such varied conditions that a classification is at present 
only warrantable upon a hypothetic basis, especially as the causes 
concerned in its production are mostly unknown. 

As this condition is almost invariably associated with diabetes 
mellitus, its existence in any case should always excite suspicion and 
lead to a proper examination. The quantity of fluid eliminated in 
diabetes is usually dependent upon the amount ingested. The excre- 
tion of a proportionately large amount of fluid, however, does not 
necessarily follow the ingestion directly, and a retention of a large 
amount may occur ; it has been shown, as a matter of fact, that the 
diabetic patient excretes liquids with greater difficulty than the 
healthy subject. At the same time it should be borne in mind that 
the polyuria in diabetes is not necessarily continuous, and that periods 
during which a normal or even a subnormal amount of urine is ob- 
served may alternate with true polyuria. From 2 to 26 or even 50 
litres may be passed within twenty-four hours. Intercurrent dis- 
eases of a febrile character may modify the quantity very materially 
and cause the elimination of a normal or subnormal amount. 

The causs of the polyuria occurring in diabetes mellitus is at pres- 
ent unknown. The ingestion of large amounts of liquids, of course, 
leads to a correspondingly large elimination, and the existing poly- 
dipsia could, hence, be made responsible for the polyuria ; the latter 
would thus be the result of an increased stimulation of the thirst- 
centre, possibly owing to the presence of some abnormal constituent 
of the blood. The polydipsia, however, may also be the result of a 
primary polyuria. 

The polyuria associated with the resorption of large pericardial, 
pleural, ascitic, and subcutaneous effusions is more readily under- 
stood, although the primum mobile may be unknown ; it depends in 
such cases entirely upon the presence of excessive quantities of fluid 
in the blood-vessels. 

A form of polyuria which has been termed "epicritic polyuria," 
is frequently observed during convalescence from acute febrile dis- 
eases, and is of some prognostic importance. Its occurrence in a 
given case is regarded by many as a good omen, especially in ty- 
phoid fever ; still it must not be forgotten that a polyuria may occur 
after the subsidence of the fever, and be followed by a considerable 
degree of oliguria, and in some cases may precede death. A polyuria 
of this kind probably always indicates the elimination of waste-prod- 
ucts which had accumulated in the blood during the course of the dis- 
ease, hut may, at the same time, be due to the presence of retained water. 



282 THE URINE. 

Second in constancy is the polyuria associated with granular 
atrophy of the kidneys, constituting one of the most important symp- 
toms of the disease. Cases have been reported in which as much as 
10,000 c.c. of urine were secreted in the twenty- four hours; 2,000 
to 4,000 c.c. represent the usual amount in such cases. Polydipsia 
usually exists at the same time, and the explanation of the polyuria 
again becomes a very difficult matter. The explanation usually given 
is based upon the following considerations : 

In granular atrophy of the kidneys large tracts of renal parenchyma 
are destroyed, the result beiug a diminution in the area of glandular 
material, which in itself would lead to a diminished secretion of 
urine. The coexisting cardiac hypertrophy, however, by raising the 
blood-pressure in the kidneys, is supposed to counterbalance the 
renal deficiency and even lead to an increase in the amount of urine. 
There seems to be some doubt as to the correctness of such an explana- 
tion, however, as the existence of hypertrophy of the left ventricle in 
the absence of glandular disease of the kidneys by no means leads to a 
degree of polyuria which is at all comparable to that observed in this 
disease. It is possible that while cardiac hypertrophy in itself may 
be one of the causative factors, still another may be a vicarious action 
of the sound glandular elements. If such is the correct explanation 
the coexisting polydipsia is merely secondary. This, however, can 
only be regarded as an hypothesis, and the diminished renal secre- 
tion associated with a gradually developing cardiac dilatation cannot 
be upheld as an absolute proof of its correctness. 

Polyuria, furthermore, has been observed in the most divers dis- 
eases of the nervous system, both functional and organic. It is fre- 
quently observed, both as transitory and a permanent symptom, in 
cases of hysteria. Large quantities of a very pale urine are secreted 
after the occurrence of severe hysterical seizures, but the same may 
be observed throughout the course of the disease. A similar con- 
dition is frequently seen in neurasthenia, migraiue, chorea, and 
epilepsy. 

On the whole, it may be said that a paroxysmal polyuria in 
nervous diseases is associated with functional derangement, while 
a continuous polyuria appears to be connected rather with true 
organic changes. It has been observed in certain cases of tabes, 
cerebro-spiual and spinal meningitis, the first stage of general pare- 
sis, tumors affecting the medulla, the cerebellum, and spinal cord, 
in injuries affecting the central nervous system, in Basedow's dis- 
ease, etc. 

Cases of idiopathic diabetes insipidus must probably be classified 
under this heading. Enormous quantities of urine may be secreted 
in this disease, being equalled only in cases of diabetes mellitus, and 
at times reaching 43 litres per diem. 



GENERAL CHARACTERISTICS OF THE URINE. 283 

Oliguria. — Oliguria is, on the whole, more frequent than polyuria, 
and is met with in almost all conditions associated with a lowered 
blood-pressure. First in order stand those cases of cardiac disease 
in which compensation has failed, whether the cardiac weakness is 
primary or occurring secondarily to other diseases — i. e., pulmonary, 
hepatic, and renal. 

The oliguria observed in the so-called continued fevers, notably 
typhoid fever, is probably also referable to the existence of cardiac 
weakness. It should be remembered, however, that a larger pro- 
portion of water is eliminated through the skin and lungs than nor- 
mally, and that a retention of fluids also undoubtedly occurs, which 
is not referable to cardiac weakness ; still other factors may be con- 
cerned in its production. 

The oliguria occurring in acute nephritis and in chronic paren- 
chymatous nephritis in all probability depends largely upon mechan- 
ical causes, the increased intra-canalicular resistance in the form of 
desquamated epithelium and tube-casts, as well as the pressure of 
the exudate upon the blood-vessels obstructing the passage of urine, 
while the functional activity of the diseased glandular elements is at 
the same time lowered. 

Upon mechanical causes, also, depend all those cases of oliguria 
which are associated with the presence of a stone or tumor pressing 
upon a portion of the urinary tract. Oliguria may occur as a nerv- 
ous manifestation in connection with puerperal eclampsia, lead-colic, 
hysteria, psychic depressions, preceding and during epileptic seizures, 
etc. Whenever there is a diminution in the amount of bodily 
fluids oliguria is also observed ; this is particularly marked in cholera 
and following severe hemorrhages. 

Obstruction to the flow of blood in the vena cava or liver, lead- 
ing to an increase of venous pressure and a decrease of arterial 
pressure in the kidneys, likewise results in oliguria, as is seen in 
atrophic hepatic cirrhosis, acute yellow atrophy, thrombosis of the 
vena cava and the renal vein, or in cases in which pressure is ex- 
erted upon these by tumors, ascitic fluid, etc. 

In any case the oliguria may go on to complete anuria, which con- 
dition not infrequently precedes death. Anuria may, however, also 
occur independently of a pre-existing oliguria, as in hysteria. 

Specific Gravity. 

The specific gravity of normal urine varies between 1.015 and 
1.025, corresponding to 1,200 to 1,500 c.c, viz, the normal amount 
of urine voided in twenty-four hours. Pathologically a specific 
gravity of 1.002 on the one hand and 1.060 on the other may occur, 
depending upon the amount of solids and fluids present, increasing 
as the solids increase, the amount of urine remaining the same, and 



284 THE URINE. 

decreasing as the amount of fluid increases, the solids remaining the 
same. The specific gravity is thus an index, in a general way, of 
the metabolic processes taking place in the body. 

The necessity of determining the specific gravity of the total 
amount of urine voided in a given case, and not that of an individual 
specimen passed during the twenty-four hours, becomes apparent 
upon considering the variations which can occur in the solids and 
liquids during the day. The ingestion of large amounts of water or 
beer would, of course, result in the passage of a correspondingly 
large quantity of urine within the next few hours, containing but a 
small amount of solids, and hence presenting a low specific gravity. 
It would be erroneous to infer a diminished excretion of solids for 
the day from such an observation, as succeeding specimens would in 
all probability be passed which present a higher specific gravity. 
An observation made upon a specimen taken from the collected 
quantity of urine of the twenty-four hours, moreover, can only then 
convey a correct idea if the quantity falls within the normal limits. 
If this should not be the case, the volume of urine observed must 
first be reduced to the normal and the specific gravity then taken. 

Supposing a known quantity of common salt to be dissolved in 
1,000 c.c. of water, so that the resulting specific gravity is 1.24, by 
doubling the amount of salt and water the specific gravity would 
still remain the same, while the amount of salt would actually be 
twice as large as at first. In order to obtain the specific gravity 
indicating the true amount of solids present it would be necessary to 
concentrate the fluid to 1,000 c.c. The specific gravity being in- 
versely proportionate to the amount of fluid secreted, the necessary 
■correction is made according to the following formula : 

Sp.gr. =^ 

in which Sp. gr. indicates the specific gravity to be determined, q 
the amount of urine actually passed, d the specific gravity observed, 
and X the normal amount of urine— L e., 1,200 c.c. 

Example : A patient has passed 3,000 c.c. of urine in the twenty- 
four hours with a specific gravity of 1.017 ; this is corrected accord- 
ing to the above formula : 

„ 3,000X17 1 _,_ 

Sl3 - gr -=T^oo- = L042 - 

From the specific gravity the amount of solids can be calculated 
with sufficient accuracy for clinical purposes by multiplying the last 
two decimal points by 2, the number obtained indicating the amount 
■of solids in 1,000 c.c. of urine. 

To illustrate the necessity of either indicating the total amount of 



GENERAL CHARACTERISTICS OF THE URINE. 285- 

urine passed within the twenty-four hours, and of taking the specific 
gravity from this collected urine, or of correcting the specific gravity 
as shown above (which latter method is far preferable, and should be 
generally adopted in urinary reports), the following case may be sup- 
posed : 

A " specimen " of urine is taken, presenting a specific gravity of 
1.002 ; by multiplying the 2 by 2, the person would be supposed 
to pass 4 grammes of solids in every 1,000 c.c. of urine. Had the 
specific gravity been observed in the total amount of urine, passed in 
the same twenty-four hours, it would have been found to be 1.012, 
the man having passed 3,000 c.c. of urine ; by multiplying 12 by 2, 
24 grammes of solids would have represented the amount in every 
1,000 c.c. — i. e., 24 x 3 = 72 grammes in toto. The same result 
would have been reached by correcting the specific gravity of 1.012 
for the normal amount of urine. 

The first calculation then would have indicated a considerable 
deficit as compared with the second. 

The following rules for practice may thus be stated : 

1. Whenever the specific gravity only is to be indicated in a uri- 
nary report it should always be the corrected one ; if this is not done, 
the amount of urine should be stated in every case. 

2. The specific gravity should always be taken from a specimen 
of the collected urine of the twenty-four hours, and never from a 
specimen ad libitum. 

From the rule, that the specific gravity of a urine is inversely pro- 
portionate to the amount of fluid eliminated it must follow that what- 
ever causes produce oliguria will also produce a high specific gravity, 
while all those causes which produce a polyuria will similarly pro- 
duce a low specific gravity, with the following exceptions : 

1. A diminished amount of urine with a lowered specific gravity 
occurs in many chronic diseases and toward the fatal termination of 
acute diseases, indicating a defective elimination of solids. 

2. The same may be observed in certain cases of oedema. 

3. Following copious diarrhoea, vomiting, and sweating. 

4. A high specific gravity is associated with polyuria in diabetes 
mellitus. 

Unfortunately the determination of the specific gravity and the 
solids contained in urines does not furnish as valuable information 
in many cases as would be expected a priori. This is largely owing 
to the fact that the organic constituents of the urine have a lower 
specific gravity than the inorganic salts, and especially the chlorides, 
which arc usually present in considerable amount. It thus not in- 
frequently happens that the nitrogenous constituents are considerably 
increased, while the specific gravity is relatively low, owing to the 
absence or a diminution in the amount of chlorides. In other words. 



286 



THE URINE. 



Fig. 75. 



while the specific gravity may be regarded as a fair index of the 
total amount of solids excreted, its increase or decrease furnishes no 
information as to the nature of the constituents causing such a change. 
Determination of the Specific Gravity. — The specific gravity of 
the urine is most conveniently determined by means of a hydrometer 
indicating degrees varying from 1.002 to 1.040. Such instruments, 

constructed especially for the examina- 
tion of urine, are termed urinometers 
(Fig. 75). A good instrument should 
have a stem, upon which the individual 
divisions are at least 1.5 mm. apart, and 
in which each division should corre- 
spond to a half degree. 

Urinometers may also be purchased 
which are provided with a thermometer, 
a matter of great convenience. Every 
instrument should be carefully tested by 
comparison with a standard hydrometer. 
In order to determine the specific 
gravity in a given case a cylindrical ves- 
sel is nearly filled with urine and the 
f urinometer slowly inserted, the reading 

||^ being taken at the lower meniscus, as 

|jp soon as the instrument has come to a rest. 

1 | |fe Precautions. — 1. The urinometer 

2^ l must be given ample room, and the read- 

^9 ing should never be taken when the in- 

strument adheres to the sides of the ves- 
sel, as owing to capillary attraction it is 
otherwise raised, causing the reading to 
become too high. 

2. The instrument must be perfectly 
dry and clean before being used, and 
should never be allowed to " drop " into 
the urine, as otherwise the weight of the 
instrument is increased by adhering drops 
of water, and the reading becomes too low. 

3. Any foam upon the surface of the 
urine should first be removed by means of a piece of filter-paper, as 
it interferes with the accuracy of the reading ; bubbles of air adher- 
ing to the instrument and thereby raising it, should be carefully re- 
moved with a feather. 

4. The specific gravity should always be determined in specimens 
taken from the twenty-four-hour urine, and corrected according to 
the formula given above. 




Urinometer. (W. Simo>\) 



GENERAL CHARACTERISTICS OF THE URINE. 



287 



5. If the quantity of urine is too small to determine its specific 
gravity with a urinometer, the following method may be advan- 
tageously employed : 

About 50 c.c. of urine are measured off into a small bottle, pro- 
vided with a ground-glass stopper, or into a pyknometer like the one 
pictured in Fig. 76, and accurately weighed. The weight of the 
urine divided by its volume gives the specific gravity, which must, 
however, be corrected for the temperature of the urine. If accuracy 
is required, such a correction should be made in every case, as the 
specific gravity increases or decreases by 1 ° for every 3 ° C. above or 
below the point, for which the instrument is registered, viz, 15° C. 
According to Bouchardat and Mercier, this method is not strictly ac- 
curate, and the following table has been constructed by which the 
proper corrections can be readily made : 



Tempera- 


Normal 


Sugar 


Tempera- 


Normal 


Sugar 


ture. 


urine. 


urine. 


ture. 


urine. 


urine. 


0° 


0.9 


1.3 


18° 


0.3 


0.6 


1 


0.9 


1.3 


19 


0.5 


0.8 


2 


0.9 


1.3 


20 


0.9 


1.0 


3 


0.9 


1.3 


21 


0.9 


1.2 


4 


0.9 


1.3 


22 


1.1 


1.4 


5 


0.9 


• 1.3 


23 


1.3 


1.6 


6 


0.8 


1.2 


24 


1.5 


1.9 


7 


0.8 


1.1 


25 


1.7 


2.2 


8 


0.7 


1.0 


26 


2.0 


2^5 


9 


0.6 


0.9 


27 


2.3 


2.8 


10 


0.5 


0.8 


28 


2.5 


3.1 


11 


0.4 


0.7 


29 


2.7 


3.4 


12 


0.3 


0.6 


30 


3.0 


3.7 


13 


0.2 


0.4 


31 


3.3 


4.0 


14 


0.1 


0.2 


32 


3.6 


4.3 


15 


0.0 


0.0 


33 


3.9 


• 4.7 


16 


0.1 


0.2 


34 


4.2 


5.1 


17 


0.2 


0.4 


35 


4.6 


5.5 



Example : Supposing the specific gravity to have been 1.030, at a 
temperature of 20° C, it would be necessary to add 0.9 to the 1.030, 
making this 1.0309 ; at a temperature of 10° C, it would similarly 
be necessary to subtract 0.5. 

Determination of the Solid Constituents. — As indicated above, 
the amount of solids can be calculated with a degree of accuracy suf- 
ficient for clinical purposes by multiplying the last two figures of the 
specific gravity by 2 ; the number obtained indicates the amount of 
solids in every 1,000 c.c. of urine. If greater accuracy is required, 
the following method may be employed : 

Five c.c. of urine, accurately measured, are placed in a watch 
crystal containing a little dry sand (sand and crystal having been 
previously weighed) ; this is placed over a dish containing concen- 
trated sulphuric acid, and under the receiver of an air-pump, which 



288 



THE URINE. 



has been made perfectly air-tight by thoroughly lubricating the 
ground-glass edge of the bell with mutton tallow and applying the 
bell with a slightly grinding movement to the ground-glass plate. 
The receiver is now exhausted and the urine allowed to remain in 
the vacuum for twenty-four hours, when the bell is again exhausted 
and left for twenty-four hours longer ; at the end of this time the 
crystal is weighed, the difference between the two weights obtained 

Ficx. 76. 




The pyknoraeter. 



indicating the amount of solids in 5 c.c. of urine, from which the 
percentage and total amount are readily calculated. 

The slight loss of ammonia which results, when this method is 
employed, scarcely affects the accuracy of the result. 



REACTION. 

The reaction of the twenty-four-hour" urine is, as a rule, acid ; 
individual specimens, passed in the course of the same twenty-four 
hours, may be either alkaline, acid, or amphoteric. 

When a mixture of several different acids is brought into contact 
with a mixture of alkalies, the acids combine with the alkalies 
according to the degree of affinity which exists between the two, and 
the amount present of each. Upon the excess of acids over alkalies, 
and vice versa, depends the resulting reaction. If the alkalies are 
not sufficient in amount to saturate the acids, an acid reaction will 
result, while an insufficient amount of acid will give rise to an alka- 
line reaction. The same principle holds good for the acids and 
alkalies giving rise to the salts present in the urine. As here the 
alkaline substances are not present in sufficient amount to saturate 



REACTION. 



289 



the acids, which can readily be seen from the following table, the 
acid reaction of normal urine is explained : 



HC1 


so 3 


p 2 o 5 


K 


Na 


NH 3 


Ca Mg 


10.1265 
6.3811 


2.3157 
1.3315 


3.0334 

0.9827 


2.5830 
1.5194 


5.4780 
5.4780 


0.5977 

0.8087 


0.0405 i 0.0880 
0.0233 0.0843 



The figures in the first column indicate the average daily amount 
of the inorganic acids and alkalies, present in the urine of twenty- 
four hours, and the figures in the second column their equivalents 
in terms of sodium, that of phosphoric acid having been estimated as 
diacid sodium phosphate. From this it is seen that the acid equiv- 
alents, 8.6953, exceed the alkaline equivalents, 7.9137, by 0.7816 
gramme of sodium. There are present then in the urine, in addi- 
tion to the normal salts of the monobasic acids, acid salts and especially 
diacid sodium phosphate, NaH 2 PO r To the latter the acidity of 
the urine is due. If, on the other hand, the alkalies exceed the acids 
in amount, an alkaline urine will result, which may occur physiolog- 
ically under various conditions. 

The so-called amphoteric reaction will be observed when the diacid 
and neutral sodium phosphates, NaH 2 P0 4 and NaH 2 P0 4 , are present 
in a certain definite proportion ; the urine then changes the color of 
red litmus paper to blue, and vice versa. 

A neutral urine is never observed under normal conditions. The 
presence of a free acid, moreover, is not possible, as it would imme- 
diately cause the formation of ammonia from the tissues of the body, 
and the urea in the urine finally would combine with any free acid, 
which might be present. 

The question now arises, how does the acidity of the urine re- 
sult, and what are the ultimate factors which will produce an alka- 
line and an amphoteric reaction? 

These are problems which as yet await a final answer. Our 
present ideas, however, may be formulated as follows : In the me- 
tabolism of the body-tissues acids are constantly produced ; chief 
among these is sulphuric acid, which results from albuminous decompo- 
sition, and hydrochloric acid, which at a certain period of digestion 
is reabsorbed into the blood together with peptones. As the alka- 
linity of the blood is due to neutral sodium phosphate and sodium 
carbonate, these salts are attacked by the free acids, as soon as they 
enter the blood, the result being the formation of acid salts, and, as 
the latter diffuse more readily through an animal membrane than 
alkaline salts, the secretion of an acid urine from the alkaline blood 
is in part explained. 

Nevertheless it is impossible to exclude a certain specific action on 
19 



290 THE URINE. 

the part of the glandular elements of the kidneys, as otherwise the 
secretion of all glands, supposing this to depend upon a process of 
filtration or diffusion only, would necessarily be acid. 

As the alkalinity of the blood increases the acidity of the urine 
decreases, until finally an alkaline urine results. The degree of the 
alkalinity of the blood, however, depends essentially upon the 
nature of the food and the secretion of the gastric juice, viz, hydro- 
chloric acid. The ingestion of vegetable food, rich in salts of or- 
ganic acids, which become oxidized in the body to the carbonates of 
the alkalies, will result in the passage of an alkaline urine, for the 
alkalies thus formed, when absorbed into the blood, are more than 
sufficient to neutralize completely all the acids present, and the elimi- 
nation of neutral sodium phosphate alone takes place. In the case 
of animal food the reverse holds good. The alkaline carbonates 
here formed are not sufficient to neutralize the excess of acids, and 
diacid phosphate of sodium is hence eliminated in large quantity. 

An amphoteric urine results whenever the elimination of neutral 
and acid sodium phosphate is the same ; such an occurrence is, 
therefore, more or less accidental. 

As the alkalinity of the blood is increased during the secretion 
of the acid gastric juice, it may frequently happen, especially follow- 
ing the ingestion of a large amount of food, that an alkaline urine 
is voided. If this does not take place the acidity of the urine is at 
least diminished, but increases again during the process of resorp- 
tion of hydrochloric acid and peptones. The statement so gener- 
ally found in text-books, that the urine secreted after a meal is alka- 
line, is not strictly correct ; in a series of observations which I made 
in this direction an alkaline urine was observed in only tw T enty per 
cent, of the cases examined. 

It may thus be stated that an alkaline urine will result under 
physiologic conditions whenever the alkaline salts present in the 
food are sufficient to neutralize all the acids formed, as occurs in the 
case of a vegetable diet, and, furthermore, whenever the period of 
gastric secretion is lengthened. 

If an acid urine is allowed to stand exposed to the air for a cer- 
tain length of time, its degree of acidity gradually diminishes, and 
the reaction finally becomes alkaline. At the same time the urine 
becomes cloudy and deposits a sediment, which consists of ammonio- 
magnesium phosphate, MgNH 4 P0 4 -f- 6H. ? 0, neutral calcium phos- 
phate, Ca 3 (POj 2 , and still later contains ammonium urate, C 5 H 2 - 
(XH 4 ) 2 N 4 3 , in addition to the constituents of the primitive nubecula 
— i. e., a few mucous corpuscles and pavement epithelial cells. The 
entire volume of urine, moreover, remains cloudy, owing to the pres- 
ence of innumerable bacteria. The odor becomes extremely disagree- 
able, and distinctly " urinous/' In short, " ammoniacal decomposi- 



REACTION. 291 

tion " has occurred. This has been shown to depend upon the action 
of certain bacteria, notably the micrococcus urese and the bacterium 
urese, which are present in the air ; these organisms cause the decom- 
position of the urea found in every urine, with the formation of 
ammonium carbonate, according to the following equations : 

CO(NH 2 ), + 2H 2 = (NH 4 ) 2 C0 3 
(NH 4 ) 2 C0 3 = 2NH 3 + H 2 + C0 2 . 

It is not the bacterium, however, which directly produces the re- 
sult, but a bacterial product, and in this case an enzyme. 

An alkaline urine, the akalinity of which is not due to am- 
moniacal fermentation, however, but to other causes, as indicated 
above, may, of course, undergo the same change as an acid urine ; 
but it is necessary to distinguish sharply between these two varieties 
of alkaline urines, as the recognition of the cause of the alkalinity is 
very often most important in diagnosis. The distinction is readily 
made by fastening a piece of sensitive red litmus-paper in the cork 
of the bottle containing the urine. If the alkalinity of the urine is 
due to the presence of ammonia, the litmus-paper will turn blue, but 
soon changes to red again when exposed to the air ; while a urine, 
the alkalinity of which is due to the presence of fixed alkalies, will 
turn red litmus-paper blue only ivhen immersed in the urine, the change 
in color at the same time persisting. 

As ammoniacal decomposition can also occur within the urinary 
passages, it is important, whenever an alkaline reaction due to the 
presence of ammonia is observed, to test the urine at once upon being- 
voided, or, still better, to procure a portion with the catheter. Such 
urines are frequently seen in cases of cystitis the result of paralysis, 
urethral stricture, gonorrhoea, etc. 

An intensely acid reaction is observed in almost all concentrated 
urines, especially in fevers, in certain diseases of the stomach, asso- 
ciated with a diminished or suspended secretion of hydrochloric acid, 
in gout, lithiasis, acute articular rheumatism, chronic Bright's dis- 
ease, diabetes, leukaemia, scurvy, etc. Whenever a very acid urine 
is secreted for a considerable length of time the possibility of 
renal irritation and the formation of concretions should be borne 
in mind. 

An alkaline urine, the alkalinity of which is not owing to the 
presence of ammonia, but to a fixed alkali, is observed in certain 
cases of debility, especially in the various forms of anaemia, follow- 
ing the resorption of alkaline transudates, the transfusion of blood, 
frequent vomiting, a prolonged cold bath, ete. It may also be due 
to the ingestion of certain drugs, viz, salts of the organic acids and 
alkaline carbonates, the former being transformed into the latter, as 



292 THE URINE. 

has been mentioned. An increase in the degree of acidity may 
similarly take place after the ingestion of mineral acids. 

Of interest is the observation of Pick that, in twenty-four to 
forty-eight hours after the crisis in pneumonia, the urine shows a 
marked fall in its acidity, becoming neutral or even alkaline. This 
phenomenon, which was observed in thirty-one out of thirty-eight 
cases, remains for a day or a day and a-half, and then the acidity re- 
turns. In all likelihood the change is due to the absorption of the 
large amounts of sodium, which are present in the exudate. 

An increase in the acidity of the urine, upon standing, has been 
repeatedly observed, and is probably due to the formation of new 
acids from pre-existing acid-yielding substances, such as certain car- 
bohydrates, alcohol, etc., which have undergone fermentation. This 
phenomenon is frequently observed in the urine of diabetic patients. 

A decrease in the acidity of normal urine upon standing is, on the 
other hand, the rule, owing to a decomposition of urate of sodium by 
the acid phosphate of sodium, acid urate of sodium and, later on, 
uric acid resulting, which are thrown down as a sediment in conse- 
quence of the diminished acidity of the urine, and which, hence, no 
longer influences its reaction. This is shown in the equations : 

I. NaH 2 P0 4 + C 5 H 2 Na 2 N 4 3 = Na,HPO, + C 5 H 3 NaX 4 3 
II. NaH.PO, + C 5 H 3 NaISrA = Na L ,HP0 4 + C 5 H 4 N 4 3 - 

Determination of the Acidity of the Urine. — The old method 
of titrating a certain amount of urine with a decinormal solution of 
sodium hydrate has now been abandoned and replaced by that of 
Freund. This is essentially based upon the observation that the 
acid reaction of the urine is referable exclusively to diacid phos- 
phates. 

Freund's Method. — In 50 c.c. of urine the total amount of phos- 
phoric acid is estimated as described on page 312. The result is 
termed T. In a second portion of 50 c.c. the monacid phosphates, 
M, are then precipitated with a normal solution of barium chloride — 
i. e., one containing 122 grammes of the crystallized salt in 1,000 
c.c. of water, — 10 c.c. being added for every 100 mgrms. of the total 
amount of phosphoric acid found. After the addition of the barium 
the mixture is diluted to 100 c.c, filtered, and the phosphoric acid 
estimated in 50 c.c. of the filtrate. The result obtained is termed 
D. Owing to the fact that the monophosphates are not only pre- 
cipitated by the addition of the barium chloride, but also a small 
amount of normal phosphates, and that a small amount of diacid 
phosphate is formed at the same time and passes into solution, an 
error is thus incurred. This, however, remains constant, and amounts 
to 3 per cent, in favor of the diacid phosphates. As the total amount 



THE CHEMISTRY OF THE URINE. 293 

of phosphoric acid is subject to fairly wide variations, even in health, 
it is best to calculate the relative proportion of T to D for 100 c.c. 
of urine, and then to determine the absolute degree of acidity for the 
twenty-four hours. Figures are thus obtained which are directly 
comparable with one another. 

Example : Supposing that T amounted to 0.386 gramme for 100 
c.c. of urine, and D to 0.338 gramme. Three per cent, of D would 
then have to be deducted for reasons just given, making the true 
value of D 0.3368. The relative proportion of T to D would then 
be 87.5, as determined according to the equation : 

0.386 : 0.3368 : : 100 : x and x = 87.5. 

Supposing, further, that the total amount of urine was 2,000 c.c, 
the total acidity for the twenty-four hours would correspond to 1,740, 
according to the equation 100 : 87.5 : : 2,000 : x, and x = 1,740, 

and the total acidity per hour to * , L e., 72.5. 

The results obtained can also be expressed in terms of hydrochloric 
acid, 100 mgrms. of the diacid phosphates corresponding to 102.8 
mgrms. of hydrochloric acid. This mode of indicating the total 
acidity of the urine would actually be the better. 

If the urine should be alkaline and cloudy, the sediment is first 
dissolved by carefully adding a one-tenth or one-fourth normal solu- 
tion of hydrochloric acid, the amount added being then deducted 
from the total acidity. Should negative values be found, these could 
be expressed in terms of sodium hydrate. 1 

With this method a complete revision of all the work previously ac- 
complished will be necessary, and the results given above have refer- 
ence only to the old method of titration with a one-tenth normal so- 
lution of sodium hydrate. 

THE CHEMISTRY OF THE URINE. 

General Chemical Composition of the Urine. — It has been 
pointed out that, owing to the influence exerted upon the chemical 
composition of the urine by many factors, such as age, sex, tempera- 
ture, digestion, exercise, etc., the figures given by different observers 
to express the absolute quantities of the various ingredients elimi- 
nated in the twenty-four hours vary within fairly wide limits. A 
general idea may, however, be formed of these constituents, and 
their average amounts under physiologic conditions, from the follow- 
ing table : 

1 The urine is carefully guarded against ammoniacal decomposition by the addition, 
to the first portion voided, of from '20 to 25 c.c. of a solution of 10 grammes of oil of 
peppermint in 100 e.c. of alcohol. 



294 THE URINE. 

Composition of Normal Human Urine of Average Specific 
Gravity, i. e., 1.020. » 





Per litre. 


Per 24 hoiirs. 


Water 


956 grms. 


1243 grms. 


Organic Matter . . .28- 


36-38 


Urea .... 


25.37 " 


33. 00* " 


Uric acid .... 


0.40 grm. 


0.52 grm. 


Hippuric acid . 


0.50 " 


0.65 " 


Creatin and creatinin 


0.80 " 


1.0 " 


Xanthin bases 


0.04 " 


0.052 " 


Coloring-matter and extractives 


4.05 grms. 


5.850 grms. 


Volatile fatty acids 






Oxalic acid 






Phenol sulphate 






Indoxyl and skatoxyl sulphate 






Paraoxyphenylacetic acid . 


Very little. 




Sugar .... 






Mucus, pepsin . 






Fatty acids 






Glycerin-phosphoric acid . 






Mineral matter . . . 16-17 grins. 


20-21 grms. 


Sodium chloride 


10.5 " 


13.65 " 


Alkaline sulphates 


3.1 " 


4.03 " 


Earthy phosphates 


0.76 grm. 


0.98 grm 


Alkaline phosphates . 


1.43 " 


1.86 " 


Silicic acid .... 
Nitric acid .... 






• Traces. 




Gases (0, CO,, N). . . I 





In pathologic conditions the following substances may also be 
found in solution : Serum-albumin, globulin, hemialbumose, pep- 
tone, mucin (nucleo-albumin), glucose, lactose, inosit, dextrin, biliary 
constituents, viz, bile acids and bile pigments, blood pigment, uroru- 
brohsematin, urorubrofuscin, melanin, leucin, ty rosin, oxy butyric 
acid, allantoin, fat, lecithin, cholesterin, acetone, alcohol, Baum- 
stark's substance, urocaninic acid, cystin, sulphuretted hydrogen, 
and still others. 

Quantitative Estimation of the Mineral Ash of the Urine. — In 
order to estimate the amount of mineral ash in the urine the follow- 
ing method may be employed : 

Fifty c.c. of urine are evaporated to dryness in a weighed porce- 
lain dish, at a temperature of 100° C, and then heated, while 
covered, over the free flame until gases cease to be evolved, care being 
taken not to heat too strongly in order to avoid sputtering. The 
residue is taken up with distilled boiling water, and, after standing, 
filtered through a Schleicher and SchiuTs filter, the weight of the ash 
of which is known. The dish and the contents of the filter are well 
washed with hot water. Filtrate and washings are set aside and the 
dish and filter dried in the oven at 115° C. The filter is now placed 
in the dish and slowly incinerated. So soon as the ash has turned 

1 Taken from Gautier. 

2 This figure, according to my experience is too high. 



THE CHEMISTRY OF THE URINE. 



295 



white the filtrate and washings are placed in the same dish, evapo- 
rated at 100° C, and then carefully heated over the free flame. 
Upon cooling in the desiccator (Fig. 77) the dish with its contents 
is weighed, the difference between its present and previous weight 
indicating the quantity of ash contained in 50 c.c. of urine. 

Precautions : 1. Care should be taken to allow the dish to be- 
come faintly red only for a moment, as some of the chlorine is other- 
wise volatilized. Some phosphoric acid may also escape and too 

Fig. 77. 




Desiccator. (W. Simon.) 

strong a heat, moreover, may cause the transformation of sulphates 
into sulphides, the organic material present acting as a reducing 
agent. 

2. If the organic ash is not completely incinerated, it is best to 
allow the dish to cool and then to moisten the ash with a few drops 
of dilute sulphuric acid, when the heating is continued. 



The Chlorides. 

The chlorides which are excreted in the urine are derived from the 
food. As they are thus present in a much larger amount than all 
other inorganic salts combined, and in quantity more than sufficient 
to supply the needs of the body-economy, the relatively large amount 
of chlorides found in the urine under physiologic conditions, as com- 
pared with the other inorganic constituents, is readily explained. 

Of the alkalies in the urine, sodium in combination with chlorine 
exists in greatest amount, and for clinical purposes it is most con- 
venient to calculate the total quantity of chlorides found in terms of 
sodium chloride ; a small proportion also occurs combined with po- 
tassium, ammonium, calcium, and magnesium. 



From 11 to 1 



of sodium chloride, representing the total 



296 THE URINE. 

quantity of chlorine, are normally eliminated in the twenty-four 
hours, the amount depending, of course, directly upon that contained 
in the food ingested. If the amount of nourishment is diminished, 
a decrease in the elimination of the chlorides is observed. If this 
is carried to the point of starvation, the chlorides disappear al- 
most entirely from the urine, the traces remaining being derived 
from the body-fluids. The latter retain tenaciously a certain amount, 
which differs but slightly from that normally present. If at this 
stage food containing sodium chloride is again taken, a portion will 
be retained in the body until the original equilibrium is restored. A 
similar retention may be observed for a few days following the in- 
gestion of large quantities of water, which causes an increased elim- 
ination of chlorides. 

This tenacity on the part of the body in retaining sodium chloride 
is strikingly seen when the potassium salt is substituted for the so- 
dium salt ; in this case the amount of the sodium in the serum of the 
blood will be found to vary but very slightly. 

It has also been shown that the excretion of sodium chloride 
can be very materially increased by the ingestion of potassium 
salts, notably the neutral potassium phosphate (K.,HP0 4 ). This is 
supposed to decompose the sodium chloride present in the serum, 
resulting in the formation of potassium chloride and neutral sodium 
phosphate, which are both eliminated as foreign material ; a point 
is finally reached, however, when the sodium chloride ceases to be 
excreted. 

This provision of the economy, in virtue of which an increase in 
the elimination of the salt is followed by its retention, and a pre- 
vious retention by an increased elimination, is supposed to be refer- 
able to the albuminous metabolism taking place in the body. It 
may be stated, as a general rule, that any increase in the amount of 
circulating albumin will be followed by an increased elimination of 
chlorides, these having been previously retained by the albuminous 
bodies in consequence of the great affinity which exists between 
them. At the same time the elimination of the chlorides is influ- 
enced by the quantity of urine excreted, increasing and decreasing 
with its volume. 

Pathologically the excretion of the chlorides may vary within 
wide limits, diminishing on the one hand to zero, and increasing 
on the other to as much as 50 grammes or more in the twenty-four 
hours. A marked diminution, going on in some cases to a total 
absence, was formerly thought to be pathognomonic of acute croup- 
ous pneumonia. More modern investigations, however, have shown 
that such a condition occurs to a greater or less degree in most acute 
febrile diseases, such as scarlatina, roseola, variola, typhus, and ty- 
phoid fevers, recurrens, and acute yellow atrophy. 



THE CHEMISTRY OF THE URINE. 297 

The explanation of this phenomenon must be sought for, first, in 
a diminished ingestion of chlorides ; secondly, in a retention of these 
in the blood, which is probably associated with an increase in the 
amount of the circulating albumin ; thirdly, in a diminished renal 
secretion of water ; fourthly, in a possible elimination of a por- 
tion of the chlorides through other channels, as in cases of severe 
diarrhoea, the formation of serous exudates, etc. Intermittent fever 
appears to be an exception to this rule ; the chlorides, it is true, are 
usually diminished, but not to the extent seen in the other diseases 
mentioned ; they have, moreover, been found to increase during and 
sometimes immediately after a paroxysm, this increase being, of 
course, followed by a corresponding diminution. 

The chlorides are diminished in all acute and chronic renal dis- 
eases associated with albuminuria, owing, to some extent, at least, 
to a diminished secretion of water. In all cases of carcinoma of 
the stomach, chronic hypersecretion of gastric juice, associated with 
dilatation, a decrease is also observed, which in certain cases of 
hypersecretion and hyperacidity, the result of gastric ulcer, may go 
on to a total absence. In ansemic conditions the chlorides are like- 
wise diminished, as also in rickets. In melancholia and idiocy a 
striking decrease is observed ; in dementia, chorea, and pseudo- 
hypertrophic paralysis this is less marked. A total absence has 
been noted in pemphigus foliaceus, and a considerable diminution in 
the beginning of impetigo, as also in chronic lead-poisoning. 

The chlorides are found in increased amount, on the other hand, 
in all conditions in which retention has previously occurred, chief 
among these being the acute febrile diseases and cases in which a re- 
sorption of exudates and transudates, associated with an increased 
diuresis, is taking place. A marked increase has also been noted in 
some cases of diabetes insipidus, in which 29 grammes have been 
eliminated in the twenty-four hours. A similar increase may occur 
in prurigo, in which, in one instance, 29. G grammes were passed in 
twenty-four hours. In cases of general paresis, during the first stage, 
an increased elimination goes hand in hand with an increased inges- 
tion of food. In epilepsy the polyuria following the attacks is as- 
sociated with an increase in the chlorides. 

Of drugs, certain diuretics, and some of the potassium salts, as has 
been mentioned, produce an increase : the chlorine contained in 
chloroform, whether administered internally or as an anaesthetic, is 
in part excreted in the form of a chloride. Salicylic acid, on the 
other hand, is said to cause a temporary diminution. 

It is of practical importance to note that in acute febrile diseases 
the diminution in the chlorides appears to vary with the intensity of 
the disease, a decrease to 0.05 gramme pro die justifying the con- 
clusion that the case under observation is of extreme gravity. It 



298 THE URINE. 

may at times also indicate the previous occurrence of severe diarrhoea 
or the formation of exudates of considerable extent. A continued 
increase, on the other hand, should lead to the conclusion that the 
patient's condition is improving. 

The elimination of the chlorides also furnishes a fair index to the 
digestive powers of the patient. This rule also holds good for most 
chronic diseases. All other causes which might lead to an increase 
or decrease being eliminated, an excretion of from 10 to 15 grammes 
indicates a fair condition of the appetite and a normal digestive 
power, a decrease being associated with the reverse. 

An increased elimination of chlorides occurring in cases of oedema, 
and associated with the existence of serous exudates, is always of 
good prognostic omen, pointing to a resorption of the fluid. 

A continued elimination of more than 15 to 20 grammes, all other 
causes being excluded, may be considered as pathognomonic of dia- 
betes insipidus. 

Test for Chlorides in the Urine. — The recognition of the chlo- 
rides in the urine is based upon the fact that the addition of a solu- 
tion of nitrate of silver causes their precipitation, the reaction taking 
place according to the following equation : 

AgN0 3 + NaCl = AgCl + NaN0 8 . 

The silver chloride thus formed is insoluble in nitric acid. 

The test is made in the following manner : After having removed 
any albumin that may be present, according to methods given else- 
where (see Albumin), a few c.c. of urine are acidified in a test-tube with 
about 10 drops of pure nitric acid, and treated with a few c.c. of 
silver nitrate solution (1 : 20). The occurrence of a white precipi- 
tate indicates the presence of chlorides. An idea may be formed at 
the same time of the quantity present ; the occurrence of a heavy, 
caseous precipitate points to a large amount. 

Quantitative Estimation of the Chlorides by the Method of 
Salkowski-Volhard. — When a solution of silver nitrate, acidified 
with nitric acid, is treated with a solution of potassium sulpho-cyanide 
or ammonium sulpho-cyanide, in the presence of a ferric salt, the 
potassium sulpho-cyanide first causes the precipitation of white silver 
sulpho-cyanide, which, like silver chloride, is insoluble in nitric acid : 

AgX0 3 + KSCN = AgSCN + EN0 3 . 

As soon as every trace of silver is precipitated, it combines with 
the ferric salt to form iron sulpho-cyanide, which is of a blood-red 
color : 

6KSCN + Fe,(S0 4 ) 3 = Fe 2 (SCN) 6 + 3K 2 S0 4 . 

If the potassium sulpho-cyanide solution is of known strength, it 
is possible to estimate accurately the amount of silver present in the 



THE CHEMISTRY OF THE URINE. 299 

solution, the ferric salt serving as an indicator of the end of the re- 
action between the silver and the potassium sulpho-cyanide. 

Application to the urine : To urine which has been acidified with 
nitric acid an excess of a silver solution of known strength is added, 
and the silver not used in the precipitation of the chlorides then esti- 
mated according to the method given above. The difference between 
the quantity thus found and the total amount used will be that con- 
sumed in the precipitation of the chlorides, from which, knowing the 
strength of the silver solution, its equivalent in terms of sodium 
chloride is readily determined. 

Reagents required : 

1. A solution of silver nitrate of such strength that every c.c. shall 
correspond to 0.01 gramme of sodium chloride. 

2. A solution of potassium sulpho-cyanide of such strength that 
25 c.c. shall correspond to 10 c.c. of the silver nitrate solution. 

3. A solution of a ferric salt, such as ammonio-ferric alum, satu- 
rated at an ordinary temperature. 

4. Nitric acid (specific gravity 1.2). 
Preparation of these solutions : 

1. As pointed out, the silver nitrate solution is made of such 
strength that every c.c. shall correspond to 0.01 gramme of sodium 
chloride ; in other words, a standard solution is employed. 

The silver nitrate must be pure, and it is best to use the crystal- 
lized salt and not the sticks wrapped in paper, which always contain 
reduced silver. In order to test the purity of the salt, about 1 
gramme is dissolved in distilled water, heated to the boiling-point, 
the silver precipitated by dilute hydrochloric acid and filtered off. 
The filtrate, when evaporated in a platinum crucible, should leave 
either no residue at all or only a very faint one ; otherwise it is nec- 
essary to recrystallize the salt until the desired degree of purity is 
reached. 

The determination of the quantity to be dissolved in 1,000 c.c. of 
water is based upon the fact that one molecule of silver nitrate 
(molecular weight 170) combines with one molecule of sodium chlo- 
ride (molecular weight 58.5) to form silver chloride and sodium 
nitrate. As the solution of nitrate of silver shall be of such strength 
that 1 c.c. corresponds to 0.01 grm. of sodium chloride, or 1,000 c.c. 
to 10 grms., the quantity to be dissolved in 1,000 c.c. is found ac- 
cording to the following equation : 

58.5 : 170 : : 10 : x ; 58.5 x 1,700 ; x '29.059. 

Theoretically, then, this quantity should be dissolved in 1,000 c.c. 
of water. It is better, however, to dissolve it in a quantity some- 
what less than 1,000 c.c, such as 900 or 950 c.c, as the silver salt 
contains water of crystallization and the weighed-off quantity would 



300 THE URINE. 

not represent the accurate amount required, but less, the correcting of 
a solution which is too strong being a much simpler matter than that 
of a solution which is too weak. 

To make this correction, or, in other words, to bring the solution 
to its proper strength, 0.15 gramme of sodium chloride which has 
been previously dried carefully by heating in a platinum crucible, is 
accurately weighed off, dissolved in a little distilled water, and further 
diluted to about 100 c.c. To this solution a few drops of a solution 
of chromate of potassium are added, when the mixture is titrated 
with the silver solution. 

The nitrate of silver will first precipitate the sodium chloride, and 
then combine with the potassium chromate, forming red silver chro- 
mate, according to the equation : 

2AgN0 3 + K 2 CrO, = Ag,CrO, + 2KN0 3 . 

The slightest orange tinge remaining after stirring indicates the 
end of the reaction. Were the solution of the silver nitrate of the 
proper strength, exactly 15 c.c. should have been used, as every c.c. 
shall represent 0.01 gramme of sodium chloride. As a matter of fact, 
less will in all probability be needed, the solution having been pur- 
posely made too strong. Its correction then becomes a simple matter, 
as it is merely necessary to determine the degree of dilution required. 

Supposing the 29.059 grammes of silver nitrate to have been dis- 
solved in 900 c.c. of water, and that 14.5 c.c. instead of 15 c.c. had 
been required to precipitate the 0.15 gramme of sodium chloride, it 
is evident that every 14.5 c.c. of the remaining solution must be 
diluted with 0.5 c.c. of water. It is, hence, only necessary to divide 
the number of c.c. of the silver nitrate solution remaining by 14.5 ; 
the result multiplied by 0.5 represents the amount of water which 
must be added in order to bring the solution to the required strength. 
Hence the rule for the correction of a solution which has been found 
too strong : 

in which C represents the number of c.c. of water, which must be 
added to the solution remaining ; N the total number of c.c. remain- 
ing after titration ; n the number of c.c. consumed in one titration ; 
and d the difference between the number of c.c. theoretically required 
and that actually used in one titration. 

In the example given the equation would then read : 

C ^936 5X0.5 = 3229 

14.5 

32.29 c.c. of distilled water are added to the remaining 936.5 c.c, 
and the strength of the solution tested by a second titration. If the 



THE CHEMISTRY OF THE URINE. 301 

solution is found too weak, it is best to make it too strong, and then 
to correct, as described. 

2. Preparation of the potassium sulpho-cyanide solution : From 
the equation AgNO s + KSCN = AgSCN + KJTO 3 , it is seen that 
one molecule of silver nitrate (molecular weight 170), combines with 
one molecule of potassium sulpho-cyanide (molecular weight 97). 
The quantity of the latter to be dissolved in 1,000 c.c. of water is 
thus found from the following equation : 

170 : 97 : : 11.6236 : x ; 170 x =11.6236X97; x = 6.6. 

As potassium sulpho-cyanide is extremely hygroscopic, a solution 
is made which is too strong, by dissolving about 10 grammes of the 
salt in 900 c.c. of distilled water. In order to bring this solution to 
its proper strength, 10 c.c. of the silver solution are diluted to 100 
c.c; 4 c.c. of nitric acid (specific gravity 1.2) and 5 c.c. of the am- 
monio-ferric alum solution are added, when the mixture is titrated 
with the potassium sulpho-cyanide solution ; the end-reaction is 
recognized by the production of a slightly reddish color, which per- 
sists on stirring. The sulpho-cyanide solution having been purposely 
made too strong, it will be found that less than 25 c.c. are needed to 
precipitate all the silver present. The quantity of water necessary 
for dilution is ascertained, as above, according to the formula : 

n 

3. The solution of ammonio-ferric alum is a solution, saturated at 
ordinary temperatures, care being taken to insure the absence of 
chlorides in the salt, which may be effected, if necessary, by recrys- 
tallization. 

Method as applied to the urine: 10 c.c. of urine are placed in a 
small stoppered flask bearing a 100 c.c. mark, diluted with 50 c.c. 
of distilled water, and acidified with 4 c.c. of nitric acid. From a 
burette 15 c.c. of the standard solution of silver nitrate are added. 
The mixture is thoroughly agitated and diluted with distilled water 
to the 100 c.c. mark. The silver chloride formed, is filtered off 
through a dry folded filter into a dry graduate ; 80 c.c. of the filtrate 
are placed in a beaker, and, after the addition of 5 c.c. of the am- 
monio-ferric alum solution, titrated with the sulpho-cyanide solution, 
until the end-reaction — i. e., a slightly reddish tinge — is seen. If 
necessary, two such titrations should be made, the sulpho-cyanide 
solution being added 1 c.c. at a time in the first, while in the second 
the total number of c.c. needed to bring about the end-reaction, less 
1 c.c, are added at onee, and then one-tenth of a e.e. at a time. 

The amount of chlorides present in the urine is calculated as fol- 
lows : 



302 THE URINE. 

Example : Total quantity of urine 600 c.c; 6.5 c.c. of the sulpho- 
cyanide solution were required to bring about the end-reaction in 80 
c.c. of the nitrate ; this would correspond to 8.125 c.c. for the total 
100 c.c. of filtrate, representing 10 c.c. of urine, as is seen from the 
equation : 

on iaa on iaa 100 n 5 11 

n : 80 : : x : 100, 80 x = 100 n, x = ^ = — , 

80 4 ' 

in which x represents the number of c.c. corresponding to 100 c.c. 
of the filtrate, and n the number of c.c. actually used. 

These 8.125 c.c. were used in precipitating the silver nitrate not 
decomposed by the chlorides. As 25 c.c. of the sulpho-cyanide so- 
lution correspond to 10 c.c. of the silver solution, the excess of silver 
solution in c.c. is found from the equation : 

25 :10: :N : x, 25x = 10N, x = ^? = ~> 

in which x represents the excess of the silver solution in c.c, 1ST that 
of the sulpho-cyanide solution, as found in the equation above, x in 
this case being 3.25 c.c. 

The difference between the total amount of silver solution employed 
(i. e., 15 c.c.) and the excess (i. e., 3.25 c.c.) indicates the number of 
c.c. necessary for the precipitation of the chlorides in 10 c.c. of urine. 
In the case under consideration 11.75 c.c. were employed. As 1 c.c. 
of the silver solution represents 0.01 gramme of sodium chloride, 
there must have been present in the 10 c.c. of urine 0.1175 gramme ; 
in 100 c.c, hence 1.175 grammes, and in the total amount — i. e., 
600 c.c of urine — 7.05 grammes. 

From these considerations the following short rule results : In- 
stead of first multiplying the number of c.c. of the potassium sulpho- 
cyanide solution, corresponding to 80 c.c. of the filtrate by -J, and 
the result by |, in order to find the number of c.c. of the potassium 
sulpho-cyanide solution representing the excess of silver nitrate in 
100 c.c. of the filtrate, and then deducting the result from 15, it is 
simpler to multiply by J directly and deduct the result from 15, the 
number of grammes of sodium chloride contained in 1,000 c.c. of 
urine being thus foimdt This figure is then corrected for the total 
amount of urine. 

The method described may be employed in the presence of albu- 
mins, albumoses, and sugar ; the urine, however, must be fresh, so as 
to insure the absence of nitrous acid. 

Direct Method. — If absolute accuracy is not required, the fol- 
lowing method may be employed : 

Ten c.c. of urine are diluted with distilled water to 100 c.c. and 
treated with a few drops of a solution of potassium chromate. This 
mixture is titrated with a one-tenth normal solution of silver nitrate 



THE CHEMISTRY OF THE URINE. 303 

until the end-reaction is reached, — i. <?., a faint orange tinge — which 
no longer disappears on stirring. The number of c.c. used multi- 
plied by 0.01 will indicate the amount of chlorides present in 10 c.c. 
of urine. 

As uric acid, the xanthin bases, hyposulphites, sulpho-cyanides, 
and pigments are also precipitated by the silver nitrate, the end- 
reaction is delayed ; moreover, unless the urine is very pale, its 
recognition may be difficult, and the error thus caused quite consid- 
erable. This is especially true of febrile urines which contain only 
a small amount of chlorides. 

Should iodides or bromides have been taken, these must first be 
removed, as the iodide and bromide of silver, which are insoluble in 
nitric acid, would give too high a value. 

To this end the following method, which is also a very accurate 
one, should be employed, its only disadvantage being the amount of 
time required. 

Estimation of the Chlorides after Incineration ( according to 
Neubauer and Salkowski). — The principle of this method is the 
destruction of all organic material and the subsequent estimation of 
the chlorides contained in the mineral ash, by one of the methods 
described. 10 c.c. of urine are evaporated to dryness in a platinum 
crucible at a temperature slightly below 100° C, after the addition 
of a little pure, dried carbonate of sodium and from 3 to 5 grammes of 
potassium nitrate. The addition of the carbonate of sodium insures the 
conversion of any ammonium chloride which may be present into 
sodium chloride ; the potassium nitrate merely acts as an oxidizing 
agent. The residue is now carefully heated at a moderate tempera- 
ture, allowed to cool, dissolved in distilled water, and accurately 
neutralized with very dilute nitric acid. In this solution the chlo- 
rides are estimated most conveniently according to the second 
method. 

Should iodides or bromides be present, the aqueous solution just 
referred to is acidified with hydrochloric acid and the iodine and 
bromine thereby liberated extracted with carbon disulphide. As 
complete removal of these bodies is, however, only possible in the 
presence of a nitrite, it is better not to rely upon the presence of any 
that may have been formed during the process of incineration, but to 
add a few drops of a solution of potassium nitrite. After extraction 
the nitrous acid is decomposed by the addition of a little urea. The 
solution is then neutralized with sodium carbonate ; should it be al- 
kaline, dilute acetic acid is added until neutral. In this solution the 
chlorides are most conveniently estimated according to the second 
method. 

Albumin and sugar, if present, should be removed before the ad- 
dition of the sodium carbonate and potassium nitrate, so as to obvi- 



304 THE TJRIXE. 

ate losses from sputtering, which would otherwise occur. Xitrous 
acid must also be removed for reasons given above. 

The Phosphates. 

The phosphates occurring in the urine are sodium, potassium, cal- 
cium, and magnesium salts of the tribasic acid H 3 P0 4 . The most 
important of these, as was pointed out in the chapter on Reaction, 
is the diacid sodium phosphate NaH.,P0 4 , to which the acidity of 
the urine is due. It is owing to the presence of this salt in the 
urine that the calcium phosphate is held in solution ; the fact, at 
least, that calcium and magnesium phosphates are thrown down 
when the urine is neutralized, would point to this conclusion. 

The composition of the phosphates is liable to considerable varia- 
tion, depending upon the degree of acidity of the urine. As would 
be expected, diacid sodium phosphate and diacid calcium phosphate 
are present in an acid urine ; in an amphoteric urine, in addition to 
these there are found disodium phosphate, mono-calcium phosphate, 
and mono-magnesium phosphate, while in an alkaline urine trisodic 
phosphate, neutral calcium phosphate, and neutral magnesium phos- 
phate may be present. 

The alkaline phosphates normally exceed the earthy phosphates 
by one-third, and sodium is combined w T ith far the greater amount 
of phosphoric acid, the potassium salt normally occurring in only 
very small amounts. 

In addition to the mineral phosphates, phosphoric acid is also ex- 
creted in combination with glycerin as glycerin-phosphoric acid, which 
need not, however, be considered in a quantitative estimation, as it is 
present only in traces. 

As in the case of the chlorides the greater portion of the phos- 
phates is derived from the food, while only a small portion is refer- 
able to the phosphorus built up in the proteid molecule, be this in 
the form of a muscle-cell, nerve-cell, red blood-corpuscle, or bone. 
But just as the percentage of sulphur varies in the different tissues, 
so also does that of phosphorus vary ; nerve-tissue, for example, 
which is very rich in lecithin and nucleins, yields relatively more 
phosphorus than muscle-tissue. 

Not all the phosphoric acid ingested, however, is excreted in the 
urine, as one-third to one-fourth of the total quantity is eliminated 
in the feces. 

The quantity of phosphoric acid excreted, which normally varies 
between 2.5 and 3 grammes, is thus largely dependent upon the 
amount ingested, increasing with an animal and decreasing with a 
vegetable diet. During starvation a considerable increase is like- 
wise observed referable, no doubt, to an increased destruction of bony 
tissue, which is very rich in the phosphates of the alkaline earths. 



THE CHEMISTRY OF THE URINE. 305 

In accordance with this view, increased amounts of calcium and mag- 
nesium are also seen during starvation. The relation between the 
excretion of phosphoric acid and nitrogen, normally 1:7, changes, 
moreover, in such a manner that both the absolute and relative 
amount of phosphoric acid, as compared with the nitrogen, increases ; 
this leads to the conclusion that in addition to the muscles some other 
tissue, rich in phosphorus and relatively poor in N, must suffer dur- 
ing the process, and the only one which could enter into considera- 
tion is bone. 

If at this time food containing phosphorus is again given,~a re- 
tention will take place, so that the general rule given in the chapter 
on Chlorides, that increased elimination is followed by a certain de- 
gree of retention, and that a previous retention is followed by an in- 
creased elimination, seems to hold good for all the mineral acids 
found in the urine (see also the chapter on Sulphates). An increased 
elimination is also caused by the ingestion of large quantities of 
water, Avhich is followed by a certain degree of retention. 

Observations on the phosphatic excretion during muscular exercise 
have not given uniform results. Mental exercise appears to cause a 
diminished excretion of the alkaline phosphates and an increased 
elimination of the earthy phosphates. The latter also takes place 
during sleep. 

The factors which influence the character of the individual phos- 
phatic salts have been considered in the chapter on Reaction, in 
which this has been shown to depend upon the alkalinity of the 
blood, and ultimately upon the quantity of acid set free by the tissues, 
or which has been absorbed during the process of digestion ; in- 
creased tissue-destruction, of course, likewise causes an increased 
elimination of phosphates. 

In disease the total amount of phosphates may either be increased 
or diminished. 

A diminished elimination is observed in most cases of acute feb- 
rile disease, such as pneumonia, typhoid fever, typhus fever, re- 
currens, during a paroxysm of intermittent fever, etc. The de- 
gree of diminution is usually proportionate to the severity of the 
disease, reaching its lowest figure as death approaches. Such a state 
of affairs may, at first sight, appear paradoxical, in view of what has 
been said above of the effects of tissue-destruction upon the elimi- 
nation of phosphates. It is necessary, however, to distinguish sharply 
between an increased production and an increased elimination : in 
all probability a retention occurs, analogous to that of the chlorides, 
which may be observed under the same conditions. It has been sup- 
posed that the phosphates set free during the process of tissue-de- 
struction are utilized in the building up of new leucocytes, and an in- 
crease in these is actually noted in some of the diseases mentioned. 
20 



306 THE URINE. 

A diminished excretion of phosphates is, however, not always ob- 
served, and an increased elimination may occur in certain cases. In 
fatal cases this condition may even persist until the time of death. 
It is very difficult to give a satisfactory explanation of this fact at 
the present time. The phenomenon, in typhoid fever at least, ap- 
pears to be connected with the intensity of the nervous manifesta- 
tions, and Robin concludes that here an increased elimination during 
the fastigium is an unfavorable omen, while an increase during 
defervescence warrants a favorable prognosis. A similar decrease in 
the phosphates has also been observed in pulmonary phthisis, associ- 
ated with high fever. 

Very interesting and important is the diminished excretion of 
phosphates associated with acute and, to some extent also, with 
chronic nephritis, amyloid degeneration of the kidneys, and the 
anseniias, in which an actual insufficiency on the part of the kidneys 
in the elimination of these salts appears to exist. 

A diminished, or, at least, no increased excretion is seen in certain 
diseases of the bones, such as osteomalacia, although an increase in 
the earthy phosphates has been noted. This may either depend 
upon a retention or an elimination through other channels. The 
earthy phosphates especially are found in greatly diminished amount, 
or may even be absent altogether in certain cases of nephritis. A 
similar condition is observed in acute and chronic rheumatism. 

During attacks of hysteria major, in contradistinction to epilepsy, 
in which an increased elimination takes place, the phosphates are 
diminished, the degree of diminution being generally proportionate 
to the intensity of the attack, increasing again together with the other 
urinary constituents with the subsequent increase in the diuresis. 
The data regarding the phosphatic elimination in nervous and men- 
tal diseases are, on the whole, very scanty and by no means uniform. 
In chronic lead-poisoning a diminution to one-third of the normal 
quantity may occur. Very low figures have been noted in Addi- 
son's disease, in acute yellow atrophy, in which a total absence may 
even occur, and in certain cases of hepatic cirrhosis. 

An increased elimination of phosphates, on the other hand, amount- 
ing in some cases to 7 or even to 9 grammes in the twenty-four 
hours, has been described under the name of phosphatic diabetes, the 
patient presenting various symptoms commonly seen in diabetes 
mellitus ; sugar, however, is usually absent. Whether or not phos- 
phatic diabetes is a disease sui generis is not certain. 

In true diabetes mellitus a curious relation has been found to exist 
between the elimination of sugar and of phosphates, the quantity of 
the latter rising and falling in an inverse ratio to the amount of 
sugar. In diabetes insipidus a slight increase is at times found. 

Corresponding to the phosphatic retention observed in acute febrile 



THE CHEMISTRY OF THE URINE. 307 

diseases an increased elimination is noted during convalescence. In 
cerebro-spinal meningitis, an increase occurs in the course of the 
disease. 

Recently an increase to 7 grammes was noted in a case of pseudo- 
leukaemia, in which the number of red corpuscles fell from 2,200,000 
to 800,000 in four days, and in which, to judge from the very care- 
ful observations made, there could be no doubt that the high degree 
of phosphaturia, which was limited to the alkaline phosphates, was 
referable to this source. In leukaemia also an increase to 7 grammes 
has been observed on the day preceding death ; commonly, however, 
the increase is but slight in this disease. 

While it is apparent that important conclusions cannot be drawn, 
on the whole, from a knowledge of the absolute phosphatic elimina- 
tion, unless it be from a study of the relation existing between the 
excretion of the alkaline and earthy phosphates, a study of the rela- 
tive phosphatic excretion seems to promise more valuable results. 
According to Ziilzer, a definite amount of the phosphates and of the 
nitrogen is referable to the destruction of albuminous material, so 
that the relation between the phosphoric acid and the nitrogen must 
be a constant one. Another portion, however, is derived from leci- 
thin, one of the most important constituents of nerve-tissue, which 
contains more phosphorus than the albuminous molecule. When- 
ever, then, the lecithin-containing tissues are more involved in the 
general metabolism than under normal conditions, the relation will 
no longer be a stable one. 

This relation which exists between the elimination of nitrogen 
and phosphoric acid has been termed the Relative Value of phosphoric 
cid. 

The relative value of phosphoric acid in the urine has been calcu- 
lated, as varying from 17 to 20, that of the blood being 3, of muscle- 
tissue 12.1, of brain 44, of bone 426 to 430. This value supposes 
the absolute value to vary between 2 and 3 grammes pro die. It is 
found according to the following equation : 

N : P 2 5 : : 100 : x, and x = 10 ° ^ P A 

in which N indicates the amount of nitrogen actually observed, 
P 2 O s the amount of phosphoric acid in the same specimen of urine, 
and x the amount of P 2 0. corresponding to 100 grammes of X. 
By observing this relative value a much better idea may be formed 
of the processes taking place in the body in disease than from a mere 
expression of the absolute phosphatic value. 

In acute febrile diseases the relative, as well as the absolute diminu- 
tion of the phosphates has been ascribed to a retention, they being 
possibly utilized in the building up oi' white blood-corpuscles. Tn 



308 THE URINE. 

the course of these diseases oscillations in the relative value are fre- 
quently observed ; during convalescence the relative, as well as the 
absolute value again rises. 

In accordance with these considerations a diminished relative ex- 
cretion of phosphoric acid should be expected in all cases associated 
with a notable elimination of leucocytes through other channels, as in 
pneumonia, for example, or a storing away of the same, as in cases 
of empyema. The facts observed are in accord with this view. 

A relative decrease has further been noted in the various forms of 
anaemia, conditions of cerebral excitation, and especially preceding 
an attack of epilepsy. In progressive paralysis, following syphilis, 
the relative value, at first low, rises greatly after the administration 
of potassium iodide, while the excretion of the earthy phosphates is 
lessened. In chronic cerebral affections, delirium tremens, and acute 
hydrocephalus a relative decrease has been noted. In mania, during 
the period of excitement, both the alkaline and earthy phosphates 
are found increased, while during the stage of depression, as also in 
melancholia, the alkaline phosphates are diminished and the earthy 
phosphates increased. On the other hand, an increase in the relative 
value has been noted in apoplexy (amounting to 34.3 in one case, two 
days after an attack), brain tumors, tabes, arthritis deformans (30), 
pernicious anaemia (23.8—58), etc. 

Of drugs bromides appear to diminish the absolute amount of phos- 
phoric acid. Cocaine and quinine cause a decrease, and salicylic acid 
an increase. A relative decrease is produced by the cerebral excit- 
ants, such as strychnine, small doses of alcohol, phosphorus, valerian, 
cold baths, salt-water baths, etc. An opposite effect is produced by 
the cerebral depressants, such as chloroform, morphin, chloral, large 
doses of alcohol, potassium bromide, mineral and vegetable acids, 
prolonged cold baths, Turkish baths, low temperature, etc. 

As is apparent from the data given, our knowledge concerning the 
excretion of phosphoric acid is as yet very limited, and the causes 
producing variations in its amount very obscure. It is quite ap- 
parent, nevertheless, that a detailed study, especially of the relative 
excretion of phosphoric acid, would, in all probability, lead to highly 
important results, and permit an insight into the metabolism of the 
individual body-tissues, as it were. In this connection the observa- 
tions of Edlefsen, on the relation existing between the destruction of 
leucocytes and the excretion of P 2 5 , deserve especial mention. 

Practical data as to diagnosis and treatment, however, can not yet 
be formulated. 

Tests for the Phosphates in the Urine. — The test for the detec- 
tion of the phosphates, occurring in the urine, depends upon the pre- 
cipitation of phosphoric acid by means of ferric chloride, as ferric phos- 
phate, which is insoluble in cold acetic acid, according to the equation : 



THE CHEMISTRY OF THE URINE. 309 

2NaH 2 P0 4 -f Fe 2 Cl 6 = Fe 2 (P0 4 ) 2 + 2NaCl + 4HC1, 
2Na 2 HP0 4 + Fe 2 Cl 6 = Fe 2 (P0 4 ) 2 + 4NaCl + 2HC1. 

The same result may be accomplished by the addition of a solution 
of uranyl nitrate ; this gives rise to the formation of uranyl phos- 
phate, which is also insoluble in acetic acid : 

Na 2 HP0 4 + 2UO.N0 3 = 2NaN0 3 + (UO) 2 HP0 4 , 
Na 2 HP0 4 + UO.NO3 = NaN0 3 + UO.H 2 P0 4 . 

Test. — A few c.c. of urine are acidified with a few drops of acetic 
acid, and treated with a few drops of a solution of ferric chloride 
(one part of the officinal solution to ten parts of water), when the 
occurrence of a yellowish-white precipitate will indicate the pres- 
ence of phosphates. 

If a solution containing an acid phosphate of the alkalies is treated 
with an alkaline hydrate, the diacid alkaline phosphate is trans- 
formed into the monacid salt, according to the equation : 

NaH 2 P0 4 + NH 4 OH = NaNH 4 HP0 4 + H 2 0. 

This is further changed into the normal salt, as represented : 

3NaNH 4 HP0 4 + NELOH = Na 3 P0 4 + (NH 4 ) 3 (P0 4 ) 2 + H 2 0. 

As the monacid and neutral salts are both readily soluble, the 
solution remains clear. If at the same timej as in the urine, a 
soluble diacid phosphate of the alkaline earths is present, this is 
likewise transformed into the monacid and finally into the neutral 
salt ; the latter, however, being insoluble, is thrown down : 

I. Ca(H 2 P0 4 ) 2 -f- 4NH 4 OH = Ca(NH 4 ) 2 (P0 4 ) 2 + 4H 2 0. 
II. 3Ca(NH 4 ) 2 (P0 4 ) 2 = Ca 3 (P0 4 ) 2 + 2(NH 4 ) 3 P0 4 . 

Test for the Earthy Phosphates. — 10 c.c. of urine are ren- 
dered alkaline with ammonia, when the occurrence of a flocculent 
precipitate will indicate their presence. 

Test for the Alkaline Phosphates. — After having removed 
the earthy phosphates from 10 c.c. of urine, as just described, the 
clear filtrate is acidified with acetic acid and tested with ferric chlo- 
ride, or uranyl nitrate, as shown above. 

The alkaline phosphates may also be detected by treating the 
ammoniacal filtrate with a few drops of magnesia mixture (1 part 
of crystallized magnesium sulphate, 2 parts of ammonium chloride, 
4 parts of ammonium hydrate, and 8 parts of distilled water), when 
ammonio-magnesium phosphate, which is almost insoluble in ammo- 
nium hydrate, Avill be thrown down. The reaction takes place be- 
tween the monacid or neutral sodium phosphate 4 and the magnesium 
sulphate, according to the equation : 

Na i HP0 4 4-MgS0 4 + NH 4 OHH-NH 4 Cl = MgNH 4 P0 4 4-NH 4 CI+Na 8 S0 4 + 11 o. 



310 THE URINE. 

Quantitative Estimation of the Total Amount of Phosphates. 

Principle. — When a solution of disodium phosphate, acidified with 
acetic acid, is treated with a solution of uranyl nitrate, or uranyl 
acetate, a dirty-looking, white precipitate of uranyl phosphate is 
thrown down, which is formed according to the equation given 
above. It is apparent that the quantity of phosphoric acid can be 
estimated accurately, if the solution of uranyl nitrate or acetate is of 
known strength. 
Solutions required : 

1. A solution of uranium nitrate of such strength that 20 c.c. 
shall correspond to 0.1 gramme of P 9 5 . 

2. A solution containing acetate of sodium and acetic acid. 

3. Tincture of cochineal. 
Preparation of these solutions : 
1. From the equation : 

2UO.N0 3 + Na 2 HP0 4 = (UO) 2 HPO± + 2NaNO s 

it is apparent that 2 molecules of uranium nitrate combine with one 
molecule of disodium phosphate to form uranium phosphate and so- 
dium nitrate. The molecular weight of uranium nitrate being 318 
and that of disodium phosphate 142, it is seen that 636 parts by 
weight of the former combine with 142 parts by weight of the 
latter. 

As 20 c.c. of the solution of uranium nitrate shall correspond to 0.1 
gramme of P 2 5 , 1,000 c.c. must be equivalent to 5 grammes of P 2 5 . 
In 142 parts by weight of disodium phosphate there would be present 
71 grammes of P 2 5 , equivalent to 636 parts by weight of uranium 
nitrate. The quantity of the latter, then, to be dissolved in 1,000 
c.c. of water will be found from the equation : 636 : 71 : : x : 5 ; 
and x = 44.78. 

44.78 grammes of uranium nitrate are weighed off and dis- 
solved in about 900 c.c. of water, the solution being purposely made 
too strong for reasons pointed out in the chapter on Chlorides. In 
order to bring this solution to its proper strength it is necessary to 
titrate with the uranium solution a solution of disodium phosphate, 
of such strength that every 50 c.c. shall contain 0.1 gramme of P 2 0., 
or 1,000 c.c. 5 grammes. The molecular weight of Na 2 HP0 4 + 
12H 2 being 358, this amount in grammes is equivalent to 179 
grammes of P 2 5 ; the quantity of P 2 5 corresponding to 5 grammes, 
in terms of Na 2 HP0 4 + 12H 2 0, is found from the equation : 358 : 
179 : : x : 5 ; and x = 10. Ten grammes of pure, dry, and non- 
deliquescent Na 2 HP0 4 are therefore dissolved in 1,000 c.c. of dis- 
tilled water. If non-deliquescent disodium phosphate is not at 
hand, about 12 grammes of the salt are dissolved in 1,000 c.c. of 
distilled water ; of this solution 50 c.c. are evaporated in a weighed 



THE CHEMISTRY OF THE URINE. 611 

platinum dish, and the residue gently heated, the disodium phosphate 
being thereby transformed into sodium pyro-phosphate, Na 4 P 2 7 , 
according to the equation : 

2Na 2 HP0 4 = Na 4 P 2 7 + H 2 0. 

The molecular weight of Na 4 P 2 7 being 266, this corresponds to 142 
grammes of P 2 5 . 

If the solution is of the correct strength — i. e., containing 0.1 
gramme of P 9 5 in 50 c.c. of water, — the residue should weigh 0.1873 
gramme, as is seen from the equation : 132 : 266 : : 0.1 : x ; and x = 
0.1873. Supposing, however, that the residue weighs 0.1921 gramme, 
it is manifest that the solution is too strong, and must be diluted, 
the degree of dilution being ascertained according to the equation : 
0.1,873 : 1,000 : : 10.921 : x; and x = 1,025; i. e., 1,000 c.c. of 
the solution must be diluted to 1,025 c.c. to make it of the proper 
strength. 

In the case given 50 c.c. were used ; the 950 c.c. are then diluted 
with the amount of water found from the equation : 1,000 : 1,025 : : 
950 : x ; and x = 953.75. Having thus obtained a solution of diso- 
dium phosphate of such strength that every 50 c.c. shall contain 0.1 
gramme of P 2 5 , this is titrated with the uranium solution which 
has been made too strong, in order to determine the amount of water 
that must be added to the latter. To this end a burette is filled 
with the uranium solution ; 50 c.c. of the disodium phosphate solu- 
tion are treated with a few drops of the tincture of cochineal and 
5 c.c. of the acetic-acid mixture (see below). This mixture is heated 
in a beaker and, as soon as the boiling-point has been reached, 
titrated with the uranium solution, until a trace of a greenish color is 
noticed in the precipitate which does not disappear on stirring. This 
point having been accurately determined by means of a second titra- 
tion, the number of c.c. of distilled water with which the remaining 
solution must be diluted is determined according to the formula : 

N.d 

C = - — , in which C represents the number of c.c. which must be 

added, N the number of c.c. remaining after the test-titration, n the 
number of c.c. consumed in one titration to bring about the end- 
reaction, and d the difference between the number of c.c. used in one 
titration and that theoretically required. The amount of distilled 
water necessary for dilution is now added and the solution again 
tested, when 20 c.c. will correspond to 0.1 gramme of P.O.. 

2. The acetie-acid mixture consists of about 100 grammes of 
acetate of sodium, dissolved in distilled water, and 100 c.c. oi'' a 30- 
per-cent. solution of aeetie acid, the whole being diluted to 1,000 
c.c. 

3. Tincture of cochineal. This may bo prepared as follows : A 



312 THE URINE. 

few grammes of cochineal granules are digested at ordinary tempera- 
tures with 250 c.c. of a mixture of 3 volumes of water and 1 volume 
of 94-per-cent. alcohol. The solution is then decanted and ready 
for use. The residue may be utilized in the preparation of a fresh 
supply of the tincture. 

Application to the Urine. — 50 c.c. of clear, filtered urine are treated 
with 5 c.c. of the acetic-acid mixture, the object being to transform 
any monacid sodium phosphate present into diacid sodium phosphate, 
and to neutralize any nitric acid that may be formed during the 
titration, as otherwise the nitric acid would cause a partial solution 
of the precipitated uranyl phosphate. A few drops of the tincture 
of cochineal are added, when the mixture is heated to the boiling- 
point, and titrated as described above; two titrations are usually 
required. 

The results are then calculated as follows : Supposing 15 c.c. of 
the uranium solution to have been used, the corresponding amount of 
P 9 5 in 50 c.c. of urine is found from the equation : 20 : 0.1 : : 15 : x ; 
and x = 0.075. The percentage-amount would, hence, be 0.075 x 
2 = 0.15. Supposing the total amount of urine to have been 2,000 
c.c, the elimination of P 9 0. would correspond to 3 grammes. 

The presence of sugar and albumin does not interfere with the 
method. 

Separate Estimation of the Earthy and Alkaline Phosphates. 
— If the alkaline and earthy phosphates are to be determined sepa- 
rately, the total amount of P 2 5 is estimated in one portion of the 
urine, while the P 2 5 in combination with the alkaline earths is de- 
termined in another, as follows : 

Two hundred c.c. of filtered urine are made strongly alkaline with 
ammonium hydrate and set aside, covered, for several hours, when 
the earthy phosphates, thus precipitated, are collected on a filter, 
washed with dilute ammonia (1 : 3), and then transferred to a beaker, 
with the aid of a little water, containing a few drops of acetic acid, 
by perforating the filter. They are then dissolved with as little 
acetic acid as possible, diluted to 50 c.c. with distilled water, and 
titrated with the uranium solution, as described. The difference be- 
tween the total amount of P.XX and the amount thus obtained indi- 
cates the quantity of alkaline phosphates present. 

Removal of the Phosphates from the Urine. — Whenever it is 
necessary to remove the phosphates from the urine, in the course of 
an analysis, as is frequently the case, the urine is rendered alkaline 
by the addition of the hydrate of an alkaline earth and precipitated 
with a soluble calcium or barium salt. The phosphates may also be 
precipitated by means of neutral or basic acetate of lead, in which 
case the excess of lead is removed by means of sulphuretted hydrogen 
or dilute sulphuric acid. 



THE CHEMISTRY OF THE URINE. 313 

The Sulphates. 

The sulphuric acid found in the urine is derived essentially from 
the albuminous material which is constantly broken down in the body, 
a very small portion only of the inorganic sulphates being referable 
to the mineral constituents of the food. As was pointed out in the 
chapter on Reaction, sulphuric acid is constantly produced in the 
body, and, coming into contact with the so-called neutral phosphates 
present in almost all the tissues, transforms these into acid phos- 
phates, according to the equation : 

2Na 2 HP0 4 -f H 2 S0 4 = 2NaH 2 P0 4 + Na 2 S0 4 , 

both appearing in the urine. The alkaline carbonates, which are 
derived from the organic salts ingested, by a process of oxidation, 
are also attacked by the sulphuric acid. 

As the amount of food ingested is gradually diminished a point is 
reached where the body most tenaciously holds any alkaline salts that 
may still be present. A new source for the neutralization of the 
acid is then found in the ammonia, which would otherwise have 
been transformed into urea. 

While the greater portion of the sulphuric acid, excreted in the 
urine, is found in the form of mineral sulphates, about one-tenth of 
the total amount may be shown to be in combination with aromatic 
substances belonging to the oxy-group ; most important among these 
are the salts of phenol, indoxyl, and skatoxyl. 

Indoxyl and skatoxyl, as will be shown later on, are derived from 
indol and skatol, which, together with phenol, are formed during 
the process of intestinal putrefaction. Their amount increases and 
decreases with the degree of putrefaction, and hence serves as a direct 
index of its intensity. 

The mineral sulphates have been termed preformed sulphates, in 
contradistinction to the others, which are known as conjugate or 
ethereal sulphates. In the following pages the former will be desig- 
nated by the letter A, the conjugate sulphates by the letter B, and 
the total sulphates as A -f- B. 

The amount of A -f B, excreted in the twenty-four hours by a 
normal individual, varies between 2 and 3 grammes, the ratio of A 
to B being as 10 : 1. 

From what has been said it is apparent, that the elimination of 
sulphates is largely dependent upon the degree of albuminous de- 
composition taking place in the tissues and fluids of the body, and 
hence to a certain extent upon the quantity of proteid material in- 
gested, the mineral sulphates occurring in such small amount in the 
food, as scarcely to affect the quantity excreted. Secondarily, the 
degree of intestinal, putrefaction plays a role. The excretion of A 
-f B is thus increased by a diet rich in animal proteids : the time 



314 THE URINE. 

after a meal, however, at which such an increase can be demonstrated 
varies greatly, depending essentially upon the time necessary for di- 
gestion. With a vegetable diet, on the other hand, the total sul- 
phates will be found diminished. During starvation A -f B is, of 
course, also diminished, this diminution affecting A especially ; but 
in some cases B may be considerably increased. 

Our present knowledge regarding the excretion of sulphates is 
very meagre, as may be seen from the following data : An increase 
in the elimination of the total sulphates is observed, as would be 
anticipated, in all cases in which an increased tissue-destruction is 
taking place, as in the acute febrile diseases. It must be remem- 
bered, however, that here the quantity excreted is not always greater 
than during convalescence, the diet remaining the same. Here, as 
elsewhere, in urinary studies, it is necessary to distinguish between a 
relative increase and an absolute decrease. In pneumonia and acute 
myelitis the highest figures have been observed, the increased elimi- 
nation during the febrile period being especially marked : 

Fever diet. Full diet. 



Fever. No fever. No fever. 

Pneumonia .... 3.51 g. 1.47 g. 2.25 g. 

Acute myelitis . . . 2.62 g. 1.52 g. 2.33 g. 

During convalescence the excretion of the sulphates is diminished, 
a retention analogous to that of the chlorides and phosphates taking 
place. In contradistinction to the latter salts, it is in all probability 
not the mineral matter proper that is demanded by the body, but the 
sulphur-containing albuminous material. 

A considerable elimination of A + B has also been observed in 
leukaemia, in which an average of 2.46 grammes is excreted, as com- 
pared with 1.51 grammes by a healthy individual, receiving the same 
amount and kind of food. In one case of acute leukaemia 5.8 
grammes were eliminated on the day preceding death. In diabetes 
mellitns, diabetes insipidus, oesophageal carcinoma, progressive mus- 
cular atrophy, pseudo-hypertrophic paralysis, and eczema an increased 
elimination has likewise been observed, while in chronic renal dis- 
eases a diminished excretion is the rule. 

A study of the elimination of the conjugate sulphates and of the 
relation existing between A and B, in disease, is still more important 
than that of the total sulphates ; but in both cases the data available 
at the present time are very scanty, and further observations are 
urgently needed. 

The conjugate sulphates, as would be expected, are increased in 
all cases of increased intestinal putrefaction. In coprostasis, the 
result of carcinoma, the ratio of the preformed to the conjugate sul- 
phates, normally 10, may diminish enormously. In one case, reported 



THE CHEMISTRY OF THE URINE. 315 

by Kast and Baas, it fell to 2, but rose to 7 and 8, and finally to 9.5 
and 15 after an artificial anus had been established. I have myself 
observed a drop to 1.5 in a case of volvulus of ten days' standing. 
Biernacki found an increase in the elimination of conjugate sulphates 
amounting to from 0.15 to 0.5 gramme pro die, in cases of chronic 
parenchymatous nephritis, going hand in hand, apparently, with a 
decrease in the secretion of hydrochloric acid by the stomach ; the 
normal amount, according to his observations, varies from 0.1973 to 
0.2227 gramme. In one case B fell from 0.4382 to 0.1505 during 
the administration of hydrochloric acid, to increase again to 0.4127 
upon its discontinuance. 

In accord with these observations are those of Wasbutzki and 
Kast. The former found an increased elimination of B in cases of 
intense bacterial fermentation taking place in the stomach, while 
hydrochloric acid was either totally absent or present in greatly 
diminished amount. A diminished elimination was observed in cases 
of intense torular fermentation, hyperchlorhydria existing at the 
same time. In the absence of hydrochloric acid, a normal or even 
a slightly diminished amount was observed in cases of intense acid 
fermentation, lactic acid and butyric acid being present in large 
quantities. 

By neutralizing the gastric juice with large closes of sodium bicar- 
bonate Kast was able to bring about a marked increase in the elim- 
ination of B, the ratio A : B having fallen from 10.3-16.1 to 2.9-6.1. 

Personal observations have led me to the same conclusion, so that 
the following rules may be formulated : 

1. A diminution in the secretion of hydrochloric acid is accom- 
panied by an increased degree of intestinal putrefaction. 

2. An increase in the secretion of hydrochloric acid is usually 
accompanied by a decrease in the degree of intestinal putrefaction. 

3. The degree of intestinal putrefaction may be measured directly 
by the elimination of the conjugate sulphates. 

(See also the chapter on the Aromatic Bodies.) 

In obstructive jaundice the excretion of B was likewise found to 
be increased, returning to the normal as soon as the permeability 
of the biliary passages had again become established. The total 
sulphates were found in diminished amount in cases of non-obstruc- 
tive jaundice. 

In cases of diarrhoea A -f- B, as well as B, is diminished, while 
A : B is increased. 

Of drugs, large doses of morphin, potassium bromide, sodium 
salicylate, and antifebrin appear to cause an increased elimination o^ 
the total sulphates, while alcohol slightly diminishes the excretion. 

Most important are the observations which have established a 
diminished excretion of the conjugate sulphates, following the inges- 



316 THE URINE. 

tion of the terpenes and camphor, Karlsbad and Marienbad water, 
which latter two, however, at first cause an increase. Kefir, in 
doses of from 1 to 1.5 litres pro die, has proved a most excellent 
remedy with which to check intestinal putrefaction. Injections of 
tannic acid and of a saturated solution of boric acid apparently pro- 
duce but little effect, unless the dose is so large as to cause symp- 
toms of poisoning. 

The points of practical interest in connection with the elimina- 
tion of the sulphates may be summarized as follows, and centre in 
the elimination of the conjugate sulphates : 

1. An increase in the conjugate sulphates in a general way points 
to increased intestinal putrefaction. The direct cause of this must, 
according to our present knowledge, be sought in a total anachlor- 
hydria, or at least in a hypochlorhydria of the gastric juice, associ- 
ated with intense bacterial fermentation, providing that lactic acid 
and butyric acid are not present in large amounts. An obstruction 
to the flow of bile and intestinal obstruction may, however, produce 
the same result. 

2. A diminution in the quantity of conjugate sulphates, on the 
other hand, may be referable to hyperchlorhydria, associated w 7 ith 
torular fermentation, ulcer of the stomach forming an exception, in 
which, notwithstanding the fact that conjugate sulphates are fre- 
quently eliminated in increased amount, hyperchlorhydria usually 
exists. 

3. In cases of diarrhoea the absolute as well as the relative quan- 
tity of A -f B and B is diminished, while A : B becomes greater. 

Tests for the Sulphates in the Urine. — The detection of the 
preformed and the combined sulphates in the urine depends upon the 
fact that the sulphates of the alkalies are precipitated by barium 
chloride, as insoluble barium sulphate, according to the equation : 

K 2 S0 4 + BaCL = BaS0 4 + 2KC1. 

In the urine the addition of barium chloride at the same time causes 
a precipitation of the phosphates. These must be kept in solution 
by the addition of an acid, acetic acid being employed for this pur- 
pose, whenever the presence of the preformed sulphates is to be 
demonstrated ; hydrochloric acid is inadmissible, as it would cause 
the decomposition of the conjugate sulphates, and set free the sul- 
phuric acid thus held. 

To test for the preformed sulphates a few c.c. of urine, strongly 
acidified with acetic acid, are treated with a few drops of a solution 
of barium chloride, when in their presence a cloud or a white pre- 
cipitate of barium sulphate will occur. 

To test for the conjugate sulphates, 25 c.c. of urine are treated with 
about the same volume of an alkaline barium chloride mixture (2 



THE CHEMISTRY OF THE URINE. 



317 



volumes of a solution of barium hydrate and 1 volume of a solution 
of barium chloride, both saturated at ordinary temperatures) and fil- 
tered after a few minutes, the preformed sulphates, as well as the 
phosphates, being thus removed. The filtrate is then strongly acidi- 
fied. with hydrochloric acid and boiled; the occurrence of a precipi- 
tate is referable to conjugate sulphates. 

Quantitative Estimation of the Sulphates. — The principle of 
the method employed is the 



Fig. 78. 



Fig. 79. 





A Gooch filter. 



same as that just described, 
the preformed sulphates 
contained in the urine form- 
ing an insoluble precipitate 
of barium sulphate, when 
treated directly with barium 
chloride, while the combined 
sulphates do so only after 
having been decomposed 
with strong hydrochloric 
acid and the application of 
heat. In order to estimate 
the amount of preformed 

and conjugate sulphates it is best to determine the total 
sulphates in one portion, and the combined sulphates 
in another, the difference between the two giving the 
preformed sulphates. 

Quantitative Estimation of the Total Sulphates. — One 
hundred c.c. of clear, filtered urine are treated with 
8 c.c. of hydrochloric acid (specific gravity 1.12) and 
heated to the boiling-point, when 20 c.c. of a satura- 
ted solution of barium chloride are added. The mix- 
ture is kept on the water-bath until the barium sul- 
phate has thoroughly settled down and the super- 
natant fluid appears clear ; this usually requires about 
one half hour. The precipitate is now filtered off 
through a Schleicher and Schull filter, or, still better, 
a Gooch filter (Fig. 78), provided with a close-fitting 
plug of asbestos, the whole having been previously 
dried and weighed. Care should be taken never 
filter to run dry, and small amounts of hot water must be added to 
the last c.c. remaining, the final traces being placed upon the filter 
with the aid of a rubber-tipped glass rod. The precipitate is 
washed with boiling water, until a specimen of the washings is no 
longer rendered cloudy, even on standing for a few minutes, on the 
addition of a drop of dilute sulphuric acid. Gum-like substances, 
as well as pigments, are removed by washing with hot alcohol (70 




A suctiou-funnol. 



to allow the 



318 THE URINE. 

per cent.), and then filling the filter two or three times with 
ether. A suction apparatus is very convenient, but not necessary ; 
a simple glass tube, bent upon itself, will answer the purpose 
(Fig. 79). 

If a paper filter has been used, it is placed in a weighed platinum 
or porcelain crucible and ignited. The ash is then heated, at first 
moderately, and almost completely covered with the lid. It is then 
heated, only half covered, for from five to seven minutes, until the con- 
tents of the crucible are white. The crucible, when cooled, is placed 
in a desiccator and weighed, the difference between the first and the 
second weighing giving the weight of the barium sulphate, obtained 
from 100 c.c. of urine. 

A reduction of some of the sulphate usually takes place during 
the process of combustion, owing to the presence of organic matter^ 
so that the weight obtained is actually too low. This error may be 
corrected in the following manner : The barium sulphate is washed 
into a small beaker with a small amount of water colored red by a 
few drops of an alcoholic solution of phenolphthalein, and titrated 
with a one-tenth normal solution of sulphuric acid, until the red 
color has disappeared. Every c.c. of the one-tenth normal solution 
corresponds to 0.004 gramme of barium sulphate, so that the actual 
amount, contained in 100 c.c. of urine, is ascertained by adding the 
figure thus found to that obtained by weighing (see below). 

Instead of correcting as just described, the ash may be moistened 
with a few drops of a dilute solution of sulphuric acid. When 
heat is then again applied any sulphide that may have formed is 
transformed into the sulphate. 

Quantitative Estimation of the Conjugate Sulphates. — One hun- 
dred c.c. of clear, filtered urine are mixed with 100 c.c. of an alka- 
line solution of barium chloride (see above), the mixture being thor- 
oughly stirred. After a few minutes it is filtered through a dry 
filter into a dry graduate to the 100 c.c. mark. This portion, 
corresponding to 50 c.c. of urine, is now strongly acidified with 
dilute hydrochloric acid and brought to the boiling-point. It is 
kept upon the boiling water-bath until the barium sulphate formed 
has settled and the supernatant fluid is clear. The precipitate is 
filtered off, washed, dried, and weighed, as described above. The 
weight thus obtained, multiplied by 2 and deducted from the amount 
found according to the first method, indicates the amount referable to 
the preformed sulphates. The molecular weight of BaS0 4 being 
232.82, that of S0 3 79.86, of H 2 S0 4 97.82, and of S 32, the figure 
expressing the amount of H 2 S0 4 , SO s , or S, corresponding to 1 
gramme of BaS0 4 , is found according to the following equations : 

232,82 : 79.86 : : 1 : x, and x = 0.34301. .-. 1 gramme of BaSO, 
= 0.34301 gramme of S0 3 . 



THE CHEMISTRY OF THE URINE. 319 

232.82 : 97.82 : : 1 : x, andx = 0.42015. .-. 1 gramme of BaS0 4 
= 0.42015 gramme of H 9 S0 4 . 

232.82 : 32 : : 1 : x, and x = 0.13744. .-. 1 gramme of BaS0 4 = 
0.13744 gramme of S. 

To calculate results it is only necessary to multiply the weight of 
the BaS0 4 by 0.34301, 0.42015, or 0.13744 in order to ascertain 
the amount of sulphuric acid contained in 50 c.c. of urine, in terms 
of SO s , H 2 S0 4 , or S, respectively. 

Neutral Sulphur. 

While the greater portion of the sulphur of the body is eliminated 
in an oxidized form, traces of non-oxidized sulphur bodies are like- 
wise found in every urine. They are collectively spoken of as the 
neutral sulphur of the urine, and under normal conditions constitute 
from 12-15 per cent, of the total sulphur. The relation existing 
between the oxidized and the neutral form is, however, inconstant, 
and varies with the character of the diet, the degree of the proteid 
metabolism, etc. 

Of the true nature of the neutral sulphur bodies, which occur in 
normal urine, comparatively little is known. At the present time 
we are only acquainted with two substances belonging to this order, 
viz, certain sulphocyanides and cystein, or a body which is closely 
related to it. The greater portion of the sulphocyanides is undoubt- 
edly derived from the saliva that has been swallowed and absorbed, 
while a smaller amount may be referable to the trace, which is said 
to be present in the normal, uncontaminated gastric juice. The 
origin of cystein on the other hand has not as yet been definitely 
ascertained. Possibly it represents an intermediary stage in the 
normal metabolism of proteid material. Under normal conditions, 
however, the greater portion is certainly oxidized to sulphuric acid, 
and traces only escape to be eliminated, as such. 

Whether or not tauro-carbaminic acid which is a derivative of 
taurin, is normally found in the urine, is as yet an open question, 
but very probable. We know, as a matter of fact, that the amount 
of neutral sulphur undergoes a distinct diminution in animals, when 
the bile is prevented from entering the intestinal canal by establishing 
an external fistula. Under pathologic conditions a corresponding 
increase is observed in cases of biliary obstruction, and the amount 
of neutral sulphur may then reach 40 per cent, of the total 
sulphur. 

Thiosulphates, which are normally found in the urine of dogs and 
cats, do not occur in human urine under normal conditions. That 
they may be present in disease lias been shown by Striimpell, who 
found them in a case of typhoid fever. Further observations, how- 
ever, are wanting. 



320 THE URINE. 

Another sulphur body belonging to this class, which Abel dis- 
covered in the urine of clogs, and which appears to be identical with 
ethyl-sulphide, has not as yet been found in the urine of man. 

The greatest increase in the amount of the neutral sulphur isobserved 
under certain pathologic conditions, which are associated with the 
appearance of cystin. Xormally this is never present in the urine, 
while traces of cy stein, or a closely related substance, as I have 
already stated, are found. The origin of cystin, like that of cystein, 
is not definitely known, but the evidence seems to point to the liver 
as the probable seat of its formation. According to Baumann and 
v. Udranszky, its appearance in the urine is closely connected with 
the formation of certain diamins, viz, cadaverin, putrescin and a third 
diamin, which is probably identical with saprin or neuridin. As 
these diamins were hitherto supposed to result only from the action 
of certain specific bacteria upon albuminous material, cystinuria was 
regarded as evidence of a definite infectious process. It is to be 
noted, however, that cystin itself does not occur in the feces, and 
that diaminuria does not necessarily accompany the cystinuria. As 
the result of personal observations I have been led to the conclusion 
that a causal connection does not exist between the two conditions, 
and that the diamins in question can be produced in the body-tissues 
directly without the intervention of micro-organisms. Like Moreigne, 
I incline to the belief that cystinuria is essentially a metabolic 
anomaly, and the result of deficient oxidation processes taking place 
in the body. 

The amount of neutral sulphur, which may be met with in cysti- 
nuria is subject to wide variation, but not infrequently exceeds 30 
per cent, of the total sulphur. As a general rule the amount of 
cystin eliminated in the 24 hours is less than 0.5 grm. At times, 
however, larger quantities are found and I have myself obtained 
over one gramme on one occasion. Clinically it is of interest in so far 
as its continued elimination may give rise to the formation of 
calculi. 

Unless cystin occurs as a deposit, its presence will scarcely 
be suspected. The substance may, however, also occur in solution, 
and it not infrequently happens that attention is first drawn toward 
its existence in this state, owing to the marked odor of sulphuretted 
hydrogen, which such urines develop on standing (see Hydrothio- 
nuria). If acetic acid is then added in excess, the characteristic 
hexagonal plates may crystallize out. The same result is also ob- 
tained by allowing the urine to undergo ammoniacal decomposition, 
as the cystin is insoluble in solutions of ammonium carbonate. 

Chemically, cystin may be regarded as the disulphide of amido- 
pethylidene lactic acid, and, according to Baumann, is represented by 
the formula : 



THE CHEMISTRY OF THE URINE. 321 

CH 3 
NH 2V | 





)C 

COOH. 
Its relation to cy stein is further represented by the equation : 

Cystin. Cystein. 

CH 3 
NH 2X | 
+ 2H=2 )C 

HS x | 

COOH. 

and I have pointed out elsewhere that cystein may be derived from 
phenyl-alanin, which latter occurs as a normal decomposition prod- 
uct of the proteicl molecule. Since putrescin, moreover, may be 
obtained from ornithin, and this from arginin, which in tarn is 
formed during the decomposition of the protamin radicle of the albu- 
minous molecule, we can readily imagine that both cystin and diamins 
will result, if for any reason the oxidation processes of the body are 
seriously impeded. The relation between phenyl-alanin — phenyl- 
tt-amido propionic acid — and cystein is represented by the formulae : 

Phenyl-alanin. Cystein. 

CH 3 — CH( NH 2 )— COOH CH 3 — C( NH 2 ) HS— COOH. 

Cystin crystallizes in hexagonal plates which are quite characteristic, 
and not likely to be confounded with other crystalline elements that 
may be present in urinary sediments. If doubt should arise, their 
solubility in ammonia and hydrochloric acid, and their insolubility 
in acetic acid, water, alcohol, and ether, will lead to their identifi- 
cation. 

The quantitative estimation of cystin is rather unsatisfactory, as 
no method is known which yields reliable results. On the whole it 
is perhaps best to determine the neutral sulphur and to refer the 
increase beyond its normal value to the presence of cystin. 

Quantitative Estimation of the Neutral Sulphur in the Urine. — In 
100 c.c. of urine the oxidized sulphur, viz, the mineral and the con- 
jugate sulphates, are estimated as described on p. 317. In the second 
portion the total sulphur is then determined, the difference indicating 
the amount of the neutral sulphur. 

To determine the total amount of sulphur, 100 c.c. of urine are 
treated with 12 grammes of a mixture of sodium and potassium car- 
bonate (11 : 14), and evaporated to dryness in a nickel crucible. The 
residue is thoroughly fused, allowed to cool and extracted with hot 
water. The carbonaceous residue is filtered off and the filtrate and 
washings treated with a few crystals of potassium permanganate. 
After heating for about 15 minutes (more potassium permanganate 
21 



322 THE URINE. 

should be added, if daring this time the solution becomes decolorized, 
when heat is again applied for 15 minutes), concentrated hydrochloric 
acid is added until the reaction is distinctly acid. This solution is 
then brought to the boiling point and treated with about 20 c.c. of 
a saturated solution of barium chloride. The barium sulphate which 
is thus formed is then collected and weighed as described on p. 318. 

Urea. 

Urea is by far the most important nitrogenous constituent of the 
urine, and represents, under normal conditions, 85 to 86 per cent, of 
the total amount of nitrogen eliminated by the kidneys. Chemic- 
ally it may be regarded as carbamide — i. e., as the amide of carbonic 
acid — and represented by the formula : 

,NH 2 

^NH 2 

It is thus a comparatively simple substance, and the question natu- 
rally arises, In what relation does urea stand to the highly complex 
albuminous molecule from which it is derived? Numerous hy- 
potheses have been offered to explain this problem, and, although 
we are in the possession of a number of very suggestive data, an ulti- 
mate answer to the question cannot be given at the present time. 

When albumin is treated with strong acids or alkalies, leucin, 
tyrosin, and asparaginic acid are formed, i. e., bodies which belong 
to the group of amido-acids, being represented by the formulae : 



Leucin. 


Tyrosin. 


Asparaginic acid. 


C 5 H 10 (NH 2 ) 
COOH 


/OH 
C 6 H 4 < 

V„H 3 (NH 2 )COOJ 


/COOH 
C 2 H 3 (XH 2 K 
H x COOH 



These bodies were regarded by Schultzen and Xencki as inter- 
mediary products in the formation of urea. As a matter of fact, it 
was shown that leucin, asparaginic acid, and glycocoll, 

/NH 2 
CH 2 < 

x COOH 

which latter can be obtained under similar conditions from connec- 
tive tissue, osseous and gelatinous tissue, are transformed, to a large 
extent at least, into urea within the body. An analogous formation 
of urea was hence supposed to occur, the transformation of amido- 
acids into uric acid, occurring in birds, being regarded as supporting 
this view, since uric acid in birds corresponds to urea in mammals. 
The manner of the transformation of amido-acids into urea in the 
body is unknown. It is conceivable that cyanic acid (COXH), may 



THE CHEMISTRY OF THE URINE. 323 

be produced as an intermediary product, the formation of urea re- 
sulting from an interaction between 2 molecules of CONH in statu 
nascendi, according to the equation : 

CONH + CONH + H 2 = C0< + C0 2 . 

NH 2 

A transformation of the amido-acids into the ammonium salts of the 
fatty acids standing next in order in the downward scale may also 
be imagined. This change being produced by a process of oxidation, 
the salts of the fatty acids would then be transformed into ammonium 
carbonate and this again into urea. 

In the case of glycocoll such a process would be represented by 
he following equations : 

Amido-acetic acid. Amnion, formate. 

I. CH 2 .NH 2 .COOH + 20 = HC0 2 .NH 2 + C0 2 

Amnion, formate. Ammonium carbonate. 

II. 2H.C0 2 .NH 2 + 20= (NHJ 2 C0 3 -f H 2 + C0 2 
III. (NH 4 ) 2 C0 8 = CO< 2 +2H 2 0. 



The possible formation of urea from ammonium carbonate in the 
body has been demonstrated by v. Schroeder and Salomon, who 
observed a fair production of urea when blood containing ammonium 
carbonate or ammonium formate was allowed to flow through isolated 
livers of dogs. 

Other hypotheses have been advanced to explain the mode of for- 
mation of urea, such as its production from ammonium carbonate, 
formed directly from albuminous material without the intermediary 
occurrence of amido-acids. 

According to Drechsel, the amido-acids are transformed into car- 
bamic acid, 2 molecules of the latter uniting to form urea, carbonic 
acid, and water : 

.NH 2 NH 2 NH 2 

CO<Q 4- CO/ = CCX^ + CO, -f- H 2 0. 
^OH \)H X NH 2 

On the other hand, it is possible that urea is not always formed in 
the same manner, and the possibility of its origin from kreatin and 
the xanthin bases cannot be altogether excluded. It is also conceiv- 
able that urea may, under certain conditions, be produced in a different 
manner by different organs. 

Numerous experiments have been made in order to ascertain defi- 
nitely in what organ or organs urea is formed during health, and 
special attention has been directed to the kidneys, the muscular tissue, 
and the liver. 



324: THE URINE. 

Opposed to the assumption that urea is formed in the kidneys are 
the facts that after extirpation of these organs an accumulation of 
urea is observed in the blood and tissues of the body, and that ex- 
periments, analogous to those made with still living livers, furnished 
a negative result. 

The same result has been reached so far as the muscular tissue of 
the body is concerned, although the curious fact, that more urea is 
found in these organs than in the blood of nephrectomized animals, 
in the typhoid stage of cholera Asiatica, etc., has so far not been 
explained. Under normal conditions, however, urea has not been 
demonstrated in the muscles. • 

There remain then for consideration the large glandular organs of 
the body, and especially the liver and spleen, in which urea is always 
demonstrable. In the liver the transformation of ammonium car- 
bonate and the ammonium salts of the fatty acids has been conclu- 
sively established. The facts that possible antecedents of urea, such 
as leucin, have been observed in the absence of urea in the urine, as 
in cases of acute yellow atrophy, and that an increase in the elimina- 
tion of ammonia goes hand-in-hand with a diminished excretion of 
urea in certain diseases of the liver, also speak strongly in favor of 
the hepatic origin of urea. 

Before going on to a consideration of the quantitative excretion 
of urea in health and disease it will be well to form an idea of its 
ultimate sources. To this end the theory of Pettenkofer should be 
recalled, according to which albuminous material exists in the body 
in two different forms — i. e., as organized albumin, — which is built 
up in the form of the tissues of the body, and as unorganized albumin, 
or circulating albumin, which must be regarded, in a manner, as a 
reserve, to be used in tissue repair, or to be broken down if not used, 
and to be replaced by the proteids ingested with the next meal. It 
may, hence, be said that, as in the case of the mineral constituents 
of the urine, the urea is referable on the one hand to the proteids 
of the food, and on the other to the proteids of the body-tissues. It 
is clear then that the elimination of urea will continue during starva- 
tion. 

It has been stated that 84 to 86.6 per cent, of all the nitrogen, 
eliminated in the urine, is found in the form of urea, the remaining 
13.4 per cent, being excreted as uric acid, hippuric acid, kreatinin, 
xanthin bases, etc. It might, hence, be supposed that an accurate 
idea of the degree of tissue destruction could be formed from a 
quantitative estimation of urea. This, however, is not the case, and 
especially in pathologic conditions, as the quantitative relations ex- 
isting between the excretion of urea and the remaining nitrogenous 
constituents are subject to wide variation. In acute yellow atrophy, 
for example, as pointed out above, urea may disappear entirely from 



THE CHEMISTRY OF THE URINE. 325 

the urine, the nitrogen being eliminated in the form of other com- 
pounds. Whenever it becomes desirable then to gain an accurate 
insight into the degree of proteid-destruction or proteid-assimilation, 
— in other words, into the nitrogenous metabolism — taking place in 
the body, it is necessary to resort to a quantitative determination of 
the total amount of nitrogen excreted by the kidneys ; the quantity 
found is then conveniently expressed in terms of urea. At the 
same time it is customary to express the amount of proteid tissue 
which is destroyed, as muscle-tissue, as this serves as a fair type of 
body-tissue in general. 

As 100 grammes of lean muscle-tissue contain about 3.4 grammes 
of nitrogen, corresponding to 7.286 grammes of urea, 1 gramme of 
the latter is equivalent to 13.72 grammes of muscle-tissue. It is, 
hence, only necessary to multiply the quantity of urea eliminated in 
the twenty-four hours, corresponding to the total amount of nitrogen 
found, by 13.72, in order to obtain an idea of the extent of albu- 
minous destruction taking place in the body. If accurate results 
are desired, it also becomes necessary to determine the amount of 
nitrogen eliminated in the feces, a knowledge of the quantity in the 
food ingested being, of course, presupposed. 

With all these data given the nitrogenous metabolism of the body 
can be accurately controlled. 

Example : A patient eliminates 50 grammes of urea in twenty- 
four hours ; these 50 grammes correspond to 50 x 13.72 — i. e., 686 
grammes of lean muscle-tissue ; on the other hand, he ingests an 
amount of nitrogenous material corresponding to only 10 grammes 
of urea, equivalent to 10 x 13.72 — i. e., 137.2 grammes of muscle- 
tissue. The difference between the amount ingested and that ex- 
creted in this case — i. e., 548.8 grammes — must be referable to the 
destruction of organized albumin. 

The value of the results of such a study in different cases, and the 
insight that can thus be obtained into the metabolic processes of the 
body, are apparent, but such studies are, unfortunately, greatly neg- 
lected. 

When the amount of nitrogen eliminated is equivalent to that in- 
gested, nih-ogenous equilibrium is said to exist. A healthy person is 
approximately in this condition. 

It has been pointed out that during starvation urea is still elimi- 
nated from the body, although in diminished amount. The question 
now arises, what happens, if at this time an amount of nitrogenous 
food is given which corresponds exactly in amount to that elimi- 
nated? Under such conditions an increased elimination of nitrogen 
takes place, all of the nitrogen ingested, in addition to that resulting 
from a breaking down of tissue, being excreted. The amount of 
nitrogen referable to the latter source, however, is somewhat less 



326 THE URINE. 

than that eliminated in the total absence of food. Unless starvation 
has been pushed too far, the body accommodates itself to the amount 
of food thus given and nitrogenous equilibrium is restored. If more 
food is allowed, an increased elimination results, again leading to 
a condition of nitrogenous equilibrium, different levels, so to speak, 
being possible. This is well illustrated by comparing the condition 
of the poorly nourished North German laboring population with 
that of the well-fed merchants, the excretion of the urea in the for- 
mer amounting to 17.5 to 33.5 grammes of urea, and in the latter 
to 30 or even 40 grammes. 

It is apparent, then, that the elimination of urea, and of nitrogen 
in general, is subject to great variation, depending upon the amount 
ingested and that resulting from tissue-destruction, which in turn is 
largely influenced by the body-weight. A statement in figures, 
expressing the daily elimination of urea and of nitrogen would, 
hence, be of very little value, especially in pathologic conditions, 
in which the amount of nitrogen ingested is frequently very small. 
The elimination of nitrogen should hence always be compared with 
the amount ingested, for which purpose the tables of Konig will 
be found most convenient. At the same time it must be remem- 
bered that not all the nitrogen taken into the body, as food, under- 
goes resorption, and that a variable amount, which in disease may 
be considerable, is eliminated with the feces, so that in accurate work 
this nitrogen also must be taken into account. In order to obviate 
the tedious estimation of nitrogen in the feces it has been proposed 
to determine the standard amount of urea which should appear in 
the urine of a healthy person under different forms of diet. Such 
experiments, of course, presuppose the control-person to be in a 
condition of nitrogenous equilibrium, which, from what has been 
said above, is readily accomplished, as the human body adapts itself 
with ease to different forms of diet. In private practice, however, 
such a procedure w T ould be difficult, but here approximative results 
can be obtained from a parallel estimation of the chlorides. In health 
the elimination of the chlorides may be placed at about one-half of 
the urea. Whenever the nitrogen resulting from tissue-destruction 
is in excess of that referable to the proteids ingested, this relation 
between the excretion of chlorides and urea will be disturbed, as the 
tissues of the body contain but very little sodium chloride. When- 
ever the amount of urea is in excess of the normal amount of 
chlorides, as indicated above, an increased tissue-destruction may 
be inferred, and vice versa. If, on the other hand, the chlorides are 
present in diminished amount, the conclusion may be drawn that a 
retention of albumins is taking place in the body ; this is frequently 
observed during the convalescence from acute febrile diseases. 

An increase in the amount of urea, and, as a matter of fact, of all 



THE CHEMISTRY OF THE URINE. 327 

the nitrogenous constituents, is observed especially in the acute 
febrile diseases, notwithstanding the diminished ingestion of nitrog- 
enous material, and is due to the greatly increased tissue-destruc- 
tion. An excretion of 50 grammes or more is here frequently ob- 
served. Formerly it was thought that the fever itself was responsible 
for this increased elimination. But this view became untenable when 
it was shown, that the excretion of urea in the beginning of a febrile 
attack is not at all proportionate to the height of the temperature, 
reaching its highest point only when the fever has been continuous 
for several days. Still larger amounts, moreover, may be eliminated 
when the fever is abating. Similar observations have since been 
repeatedly made. An increased elimination of nitrogen may also be 
noted in almost every case of ague preceding the onset of the fever. 
The latter, therefore, cannot be the only factor which causes the in- 
creased excretion of urea, and it has been suggested that the cells of 
the body have lost the power of taking up nitrogen. The question, 
however, whether this is dependent upon the increase in temperature 
or the action of certain toxic substances circulating in the blood, or 
both, must still be regarded as unanswered. 

The large increase in the elimination of nitrogen in febrile diseases 
is especially striking in those forms which end by crisis. This is 
notably the case in pneumonia, in which it may persist for two or 
three days after the occurrence of the crisis. The assumption of an 
underlying insufficiency on the part of the cells furnishes a very sat- 
isfactory explanation for the continued increased elimination of urea. 
An increase beyond the amount eliminated during the febrile stage 
is possibly owing to a certain degree of retention analogous to that 
occurring in the case of the mineral constituents of the urine. 

The only exception to the rule that the urea is increased in acute 
febrile diseases is, apparently, acute yellow atrophy, in which the 
excretion of urea is not only greatly diminished, but may altogether 
cease, its place being taken by other nitrogenous bodies, and notably 
leucin and ty rosin. 

Among afebrile diseases, in which an increased elimination of urea 
has been noted, must be mentioned the ordinary forms of diabetes 
mellitus, in which the highest figures have been obtained, viz, 150 
grammes or more pro die. This observation is, in all probability, 
explained by the ingestion of excessive amounts of proteid food by such 
patients, but carefully conducted experiments seem to show that a 
not inconsiderable portion of the urea is directly referable to increased 
tissue-destruction. The interesting cases described by Hirschfeld, 
which will be considered later on, form an exception to this rule. 

An increase is also observed in dyspnoeic conditions, and particu- 
larly in pneumonia, where it is most marked on the day following 
the greatest difficulty in breathing. These observations, however, 



328 THE URINE. 

are not free from objections, as an increase has also been noted in 
conditions of apnoea. 

A moderate increase has been found in cases of pernicious anaemia, 
in severe cases of leukaemia, scurvy, minor chorea, and paralysis 
agitans. Observations made in cases of hystero-epilepsy have given 
rise to conflicting results. It is claimed, on the one hand, that the 
excretion of urea is diminished, following the convulsive seizures of a 
hystero-epileptic nature, in contradistinction to an increased elimina- 
tion following true epileptic attacks. 

In cases of functional albuminuria associated with an increased 
elimination of uric acid or oxalic acid, or of both, as well as in 
numerous cases of gastro-intestinal disease, I have observed an in- 
creased elimination of urea, and believe that in the treatment of these 
diseases a systematic study of the excretion of nitrogen is of funda- 
mental importance. 

Of drugs, an increased elimination is produced by coffee, caffein, 
morphiu, codeia, ammonium chloride, sodium and potassium chloride, 
carbonate of lithia, following the ingestion of large amounts of water, 
etc. The data concerning the action of quinine, salicylic acid, cold 
baths, etc., are very conflicting. A large increase has been observed 
in cases of phosphorus-poisoning. 

Electricity also appears to exert a marked influence upon the ex- 
cretion of urea, producing an increased elimination. 

The diminished elimination of urea observed in certain diseases of 
the liver, notably in acute yellow atrophy, carcinoma, cirrhosis, and 
even in Weyl's disease, is of especial interest and is in perfect accord 
Avith the theory that the liver is the main seat of its production. 

As has been stated, urea may altogether disappear from the urine 
in acute yellow atrophy and also in Weyl's disease, notwithstanding 
the frequently not inconsiderable degree of fever. In cirrhosis, 
hyperemia of the portal system has been thought to cause the dimi- 
nution, which may be further increased in some cases by the occur- 
rence of ascites. In short, the factors which may be regarded as 
causing a diminished elimination of urea in hepatic diseases may be 
summarized under the following headings : 

1. Destruction of hepatic parenchyma. 

2. A diminished velocity of the flow of blood through the liver. 

3. Insufficient excretion of bile, and coincident digestive disturb- 
ances. 

Whenever there is disease affecting that portion of the renal paren- 
chyma which is especially concerned in the elimination of urea, a 
diminished amount will, of course, be met with, and carefully con- 
ducted observations upon the excretion of the various urinary con- 
stituents would undoubtedly be of considerable value from a diag- 
nostic as well as a therapeutic standpoint. As the glomeruli of the 



THE CHEMISTRY OF THE URINE. 329 

kidneys are mainly concerned in the elimination of water and salts 
from the blood, and as the striated epithelium of the convoluted 
tubules appears to provide for the excretion of urea, the elimination 
of a fair amount of the latter with a diminished elimination of salts, 
the phosphates being here of especial interest, as they are derived to a 
large extent from albuminous material, would point more particularly 
to glomerular disease. On the other hand, a fair excretion" of phos- 
phates and a diminished excretion of urea would be indicative of 
tubular disease. Whenever the glomeruli and tubuli contorti are 
equally diseased an insufficient elimination of both phosphates and 
urea will be observed. 

While, as a rule, the excretion of urea is greatly increased in 
diabetes mellitus, certain cases, which have been elaborately described 
by Hirschfeld, must be excepted. His researches have established 
beyond a doubt that the resorption of nitrogenous material from the 
intestines may be very much below normal, and with it the elimina- 
tion of urea. Upon these grounds he has advocated the recognition 
of a distinct form of diabetes, which is characterized by a com- 
paratively rapid course, the occurrence of colicky abdominal pains, 
before or at the onset of the diabetic symptoms proper, the existence 
of pancreatic lesions in a certain proportion of the cases, a more 
moderate degree of polyuria, etc. 

In mental diseases a diminished excretion of urea has been ob- 
served in melancholia and in the more advanced stages of general 
paresis, while an increase is associated with the increased ingestion 
of food, during the first stage of profound dementia. 

Following epileptic, cataleptic, and hysterical seizures, as well as 
in pseudo-hypertrophic paralysis, a decrease has been noted by some 
observers. 

The diminished excretion observed in Addison's disease has also 
been regarded as of nervous origin. 

All forms of chronic, non-progressive anamiia are associated with 
a decrease, as are also osteomalacia, impetigo, lepra, chronic rheu- 
matism, etc. In chronic lead-poisoning the elimination of urea may 
be greatly diminished. 

Of the influence of drugs in bringing: about a diminished eXCre- 
tion of urea but little is known. 

In conclusion, the relation existing between phosphatic excretion 
and that of nitrogen should be especially noted, and the reader is 
referred to that chapter. 

Properties of Urea. — Urea crystallizes in two forms, viz, in 
long, fine white needles, if rapidly formed, or in long, colorless. 
quadratic rhombic prisms, when allowed to crystallize gradually from 
its solutions. 

At 100° C. it begins to show signs of decomposition, at 130° to 



330 THE URINE. 

132° C. it melts, and when heated still further it is decomposed 
into cyanic acid and ammonia, of which the former is immediately 
transformed into its polymeric compound, cyanuric acid. The reac- 
tion which takes place is represented by the equations : 

/NH, 

I. CO< = CONH + NH 3 . 

\NH 2 

II. 3CONH = CAN3H3. 

Biuret is formed as an intermediary product during this decom- 
position, 2 molecules of urea yielding 1 molecule of ammonia and 
1 molecule of biuret, as represented in the equation : 

/NH 2 /NH 2 

yMt= N&H + NH.. 

NH 2 NH 2 

As this substance, which may be obtained by dissolving the resi- 
due remaining, after all the ammonia has been driven off, by careful 
heating, yields a beautiful reddish-violet color, when a drop or two 
of a very dilute solution of sulphate of copper is added to its solu- 
tion, alkalinized with sodium hydrate, this reaction may be employed 
as a test in the detection of urea (Biuret Test), 

Urea is readily soluble in water, fairly so in alcohol, and insol- 
uble in anhydrous ether and benzol. The aqueous solution of urea 
is neutral in reaction, but combines with acids, bases, and salts to 
form molecular compounds. 

Of special interest are the compounds of urea with nitric acid, 
oxalic acid, and mercuric nitrate. Urea nitrate, CON 2 H 4 .HN0 3 , 
crystallizes in two different forms : in thin rhombic or six-sided 
colorless plates, which are frequently observed arranged like shingles 
one on top of the other, when rapidly formed (Fig. 80), while larger 
and thicker rhombic columns or plates are obtained if the process of 
crystallization is allowed to proceed more slowly. Urea nitrate is 
readily soluble in distilled water, while in alcohol and water, con- 
taining nitric acid, it dissolves with difficulty. Upon heating it evap- 
orates without leaving a residue. 

Urea oxalate, CON 2 H 4 .C 2 H 2 4 , crystallizes in rhombic or six- 
sided prisms or plates (Fig. 81), which are less soluble in water than 
the nitrate ; in alcohol, and water containing oxalic acid, it is only 
imperfectly soluble. 

With mercuric nitrate urea forms three different compounds, accord- 
ing to the concentration of the two solutions, viz, (CON 2 H 4 )Hg 2 (N0 3 ) 4 , 



THE CHEMISTRY OF THE URINE. 



331 



(CON 2 H 4 ).Hg3(N0 3 ) 6 , and (CON a H 4 ) 2 .Hg(NO s ) ? + 3HgO. The lat- 
ter compound is of special importance, as Liebig's quantitative esti- 
mation of urea is based upon its formation. It results when a 



Fig. 80. 




Nitrate of urea crystals. (Krukenbekg, after Kuhke.) 

2-per-cent. solution of urea is treated with a dilute solution of mer- 
curic nitrate, the reaction taking place according to the equation : 

2CON 2 H 4 + 4Hg(N0 3 ) 2 -f 3H 2 = [2(CON 2 H 4 ) 2 Hg(N0 3 ) 2 + 3HgO] + 6HN0 3 . 

Very important is the behavior of urea, when treated with a solu- 
tion of sodium hypochlorite or hypobromite, the most usual method 




v&0 



Oxalate of urea crystals. (Krukenberg, after Kviink.) 



of estimating urea being based upon this reaction, which may be 
represented by the equation : 

CONJT, + 3NaOBr = 3NaBr + 2N + CO a -j- 2H 2 0. 



332 THE URINE. 

In the chapter on Reaction it was pointed out that urine, when 
exposed to the air, gradually undergoes amrnoniacal decomposition, and 
that this process is due to the action of a non-organized ferment ; the 
ammonia is liberated, according to the equation : 

NH 2 

CO/ + H 2 = 2XH 3 -f CO,. 

\\H 2 

The same decomposition may be effected by heating a watery solu- 
tion of urea in a sealed tube to 100° C. 

It might be supposed that an accurate estimation of urea could be 
made by adding a solution of the ferment, which can readily be 
obtained, to a known quantity of urine, and then to determine the 
amount of ammonia liberated, 34 parts of the latter corresponding 
to 60 parts of urea. The complete decomposition of the urea is, 
however, only obtained with difficulty, so that the method is a very 
tedious one. The same objection, although to a less degree, can also 
be urged against the method commonly employed, viz, the hypobro- 
mite method (which see), as 1 gramme of urea does not yield 372.7 
c.c. of nitrogen, which would be theoretically required, but, at most, 
only 354.3 c.c. 

Separation of Urea from the Urine. — From 50 to 100 c.c. of 
urine are evaporated to a syrupy consistence upon the water-bath, and 
•extracted with 100 to 150 c.c. of strong alcohol, by rubbing up the 
residue, while still hot, with the alcohol. Upon cooling, the mixture 
is filtered, the alcohol evaporated, and the residue treated with pure, 
cold nitric acid. Urea nitrate then separates out either immediately 
or on standing. After twenty-four hours the crystalline mass is 
collected on a muslin filter, well strained and freed from liquid, 
by placing it upon plates of clay. It is then dissolved in hot water, 
and the solution, if strongly colored, gently warmed with animal 
charcoal and filtered. This solution is neutralized with barium car- 
bonate, and rendered alkaline with barium hydrate. The urea nitrate 
is thus decomposed, barium nitrate and urea being formed : 

200X^.11X03 + BaC0 3 = 2COX 2 H 4 + Ba(N0 3 ) 2 + H 2 0. 

The barium is now removed by passing a stream of carbon dioxide 
through the solution and filtering off the precipitate. The filtrate 
is evaporated until any barium nitrate still remaining crystallizes 
out. This is removed by decantation, when upon further evapora- 
tion the urea crystallizes out, and may be dried between layers of 
filter-paper and recrystallized from 95 to 98 per cent, alcohol. The 
crystals thus formed may now be subjected to further tests. To this 
end a few drops of an aqueous solution are added to a few c.c. of a 
sodium hypobromite solution, when in the presence of urea bubbles 



THE CHEMISTRY OF THE URINE. 333 

of gas will be given off. With a solution of sodium hypochlorite 
the same result may be obtained, but in this case the evolution of gas 
only takes place upon the application of heat. The formation of 
biuret may also be demonstrated by carefully melting a few of the 
crystals in a test-tube, dissolving the residue, when cool, in a little 
water, and alkalinizing the solution with a little sodium hydrate ; 
upon the addition of a drop or two of a dilute solution of sulphate 
of copper a beautiful reddish-violet color will develop, owing to the 
presence of biuret. 

The addition of oxalic or nitric acid to a solution of urea will give 
rise to the formation of urea nitrate and oxalate, as described above. 

This latter test may very conveniently be made under the micro- 
scope. A drop of the concentrated solution is placed upon a slide, 
covered, and a drop of pure nitric acid added from the side. Crystals 
of urea nitrate will then be seen to separate out, and may be recog- 
nized by their characteristic shingle-like arrangement (see Fig. 80). 

When a urine is very rich in urea the mere addition of nitric acid 
will cause a more or less abundant precipitation of urea nitrate, and 
with this simple test an idea may even be formed of the amount 
present. An appearance of hoar-frost is thus noted when not less 
than 25 grammes are present in the litre, while the formation of 
spangles of urea nitrate requires the presence of at least 45 grammes, 
and a heavy sediment occurs when 50 grammes or more are present. 

Quantitative Estimation of Urea. — The only method which will 
be considered in detail is the one based upon the decomposition of 
urea into carbon dioxide and nitrogen, in the presence of sodium 
hypobromite. The reaction takes place according to the equation : 

CON 2 H, -f 3NaOBr = NaBr + CO, + 2H 2 + 2N. 

The carbon dioxide thus formed is absorbed by an excess of sodium 
hydrate, added to the hypobromite solution, while the nitrogen is set 
free, and can be suitably collected and measured ; the determination 
of the corresponding amount of urea then becomes a simple matter. 
The only solution that is necessary is one of sodium hypobromite, 
containing an excess of sodium hydrate. A 30-per-cent. solution of 
the latter should be kept on hand and the sodium hypobromite solu- 
tion prepared, when required. To this end 70 c.c. of the sodium 
hydrate solution are diluted with 180 c.c. of water and treated with 
5 c.c. of bromine, in a bottle provided with a ground-glass stopper, 
the mixture being thoroughly shaken until every trace of free 
bromine has disappeared. The sodium hypobromite solution, if 
kept in a perfectly dark and cool place, may be preserved for a week 
or two. The reaction which takes place between the sodium hydrate 
and the bromine may be represented by the equation : 

2NaOH + 2Br= NaBr+ NaOBr-+ 1I..O. 



334 THE URINE. 

Various forms of apparatus, termed areometers, have been sug- 
gested for the estimation of urea, by this method. One which I 
have found very satisfactory is represented in Fig. 82. It consists 
essentially of a burette, C, with an ascending rubber tube attached 
to the reservoir B, which can be raised or lowered, as is required for 
the purpose of equalizing the pressure, after the collection of the gas. 
A descending tube leads to a wide-mouthed bottle, A, which con- 
tains the hypobromite solution. This is closed by a tightly fitting 
rubber stopper, to which a loop of platinum wire is attached carry- 
ing a little bucket made of glass or porcelain ; this can be swung 
from its support by inclining the bottle. 

Method. — The rubber stopper is removed from the bottle A, and 
water poured into B until the system BCA is filled to such an ex- 
tent that the water-level is visible in B above the point where the 
rubber tube is attached. About 25 to 30 c.c. of the hypobromite 
solution are placed in the bottle A, and two c.c. of urine into the little 
bucket ; this is then attached to the wire loop. The stopper is now 
carefully adjusted and the water in B and C brought to the same 
level, when the first reading is taken. A is then inclined until the 
little bucket drops into the liquid below. The nitrogen which is 
liberated collects in the burette C, the water falls in C and rises 
in B. After twenty to thirty minutes the pressure in C is equalized 
by lowering B, until the water in both tubes has reached the same 
level. The second reading is then taken, the difference between the 
two indicating the volume of nitrogen liberated from 2 c.c. of urine 
at the temperature of the water in CB, which, as well as the baro- 
metric pressure, should be previously noted. 

As the volume of gases is greatly influenced by the temperature, 
the barometric pressure, and the tension of the aqueous vapor, it 
becomes necessary, in order that the results reached shall be com- 
parable to those obtained by other observers, to reduce the volume 
of nitrogen actually noted to a certain standard. This has been 
placed at 0° C. and 760 mercury millimetres pressure, in the absence 
of moisture. This correction is made according to the following 

formula : V = „ nr , ,' ~ ^o /^ttt, in which V represents the cor- 

VbO.(l -J- O.OOobb.t) 

rected volume of the gas in terms of c.c), v the volume actually ob- 
served, B the barometric pressure in Hgmm., T the tension of the 
aqueous vapor at the temperature noted, t. The volume of nitrogen 
observed being thus corrected, the calculation of the corresponding 
amount of urea is based upon the following considerations : From 
the formula CON 2 H^ it is apparent that 2 atoms of nitrogen are 
contained in 1 molecule of urea ; in other words, that 28 parts by 
weight of nitrogen correspond to 60 parts by weight of urea. The 
equivalent of 1 gramme of urea is then found according to the 



THE CHEMISTRY OF THE URINE. 



335 



Fig. 82. 



equation : 60 : 28 : : 1 : x, and x = 0.46666. The volume corre- 
sponding to 0.4666 gramme of dry nitrogen at 0° C. and 760 
Hgmm. pressure is 372.7 c.c. It has been found, however, that 
only 354.3 c.c. of nitrogen are 
evolved from 1 gramme of urea 
at best, when the hypobromite 
method is employed. Knowing 
that 354.3 c.c. of nitrogen corre- 
spond to 1 gramme of urea, the 
amount of urea, to which the vol- 
ume of nitrogen actually observed 
is referable, would then be found 
according to the equation : 1 : 

y 
354.3 : : x : y, and x = - Q . Q , in 

which y denotes the number of 
c.c. of nitrogen evolved from 2 
c.c. of urine, and x the correspon- 
ding amount of urea. In order 
to ascertain the percentage-amount 
of urea it is only necessary to mul- 
tiply the figure just obtained by 
50. 

Precautions : 1. The urine must 
be free from albumin. 2. It should 
contain only about 1 per cent, of 
urea — i. e., not more than 0.025 
gramme in 2 c.c. Whenever a 
greater amount is noted, therefore, 
the urine is diluted to the proper 
degree, due allowance being made 
in the calculation. 

In ordinary clinical work the 
barometric pressure, as well as the tension of the aqueous vapor, 
may be ignored, and in the tables appended the corresponding 
amount of urea may be directly read off at the temperatures 5°, 10°, 




The author's areometer. 



15°, 20°, 25°, 



and 30° C. 



336 



THE URINE. 



Urea. Table for a Temperature of 5° C. 





1 


Vio 


7io 


Vio 


4 /io 


Vio 


Vio 


Vio 


Vio 


Vio 


1 


1.32 


1.45 


1.58 


1.71 


1.85 


1.98 


2.11 


2.24 


2.37 


2.51 


2 


2.64 


2.77 


2.90 


3.03 


3.17 


3.30 


3.43 


3.56 


3.69 


3.83 


3 


3.96 


4.09 


4.22 


4.36 


4.49 


4.62 


4.75 


4.88 


5.02 


5.15 


4 


5.28 


5.41 


5.54 


5.68 


5.81 


5.94 


6.07 


6.20 


6.34 


6.47 


5 


6.60 


6.73 


6.87 


7.00 


7.13 


7.26 


7.39 


7.53 


7.66 


7.79 


6 


7.92 


8.05 


8.19 


8.32 


8.45 


8.5S 


8.71 


8.85 


8.98 


9.11 


7 


9.24 


9.38 


9.51 


9.64 


9.77 


9.90 


10.04 


10.17 


10.30 


10.43 


8 


10.56 


10.70 


10.83 


10.96 


11.09 


11.22 


11.36 


11.49 


11.62 


11.75 


9 


11.89 


12.02 


12.15 


12.28 


12.41 


12.55 


12.68 


12.81 


12.94 


13.07 


10 


13.21 


13.34 


13.47 


13.60 


13.73 


13.87 


14.00 


14.13 


14.26 


14.39 


11 


14.53 


14.66 


14.79 


14.92 


15.06 


15.19 


15.32 


15.45 


15.58 


15.72 


12 


15.85 


15.98 


16.11 


16.24 


16.38 


16.51 


16.64 


16.77 


16.90 


17.04 


13 


17.17 


17.30 


17.43 


17.57 


17.70 


17.83 


17.96 


18.09 


18.23 


18.36 


14 


18.49 


18.62 


18.75 


18.89 


19.02 


19.15 


19.2S 


19.41 


19.55 


19.68 


15 


19.81 


19.94 


20.08 


20.21 


20.34 


20.47 


20.60 


20.74 


20.87 


21.00 


16 


21.13 


21.26 


21.40 


21.53 


21.66 


21.79 


21.92 


23.06 


22.19 


22.32 


17 


22.45 


23.59 


22.72 


22.85 


22.98 


23.11 


23.25 


23.38 


23.51 


23.64 


18 


23.77 


23.91 


24.04 


24.17 


24.30 


24.43 


24.57 


24.70 


24.83 


24.96 


19 


25.10 


25.23 


25.36 


25.49 


25.62 


25.76 


25.89 


26.02 


26.15 


26.28 


20 


26.42 


26.55 


26.68 


26.81 


26.94 


27.08 


27.21 


27.34 


27.47 


27.60 


21 


27.74 


27.87 


28.00 


28.13 


28.27 


28.40 


28.55 


28.66 


28.79 


28.93 


22 


29.06 


29.19 


29.32 


29.45 


29.59 


29.72 


29.85 


29.98 


30.11 


30.25 


23 


30.38 


30.51 


30.64 


30.78 


30.91 


31.04 


31.17 


31.30 


31.44 


31.57 


24 


31.70 


31.83 


31.96 


32.10 


32.23 


32.36 


32.49 


32.62 


32.76 


32.89 


25 


33.02 


33.15 


33.29 


33.42 


33.55 


33.68 


33.81 


33.95 


34.08 


34.21 


26 


34.34 


34.47 


34.61 


34.74 


34.87 


35.00 


35.13 


35.27 


35.40 


35.53 


27 


35.66 


35.80 


35.93 


36.06 


36.19 


36.32 


36.46 


36.59 


36.72 


36.85 


28 


36.98 


37 12 


37.25 


37.38 


37.51 


37.64 


37.78 


37.91 


38.04 


38.17 


29 


38.31 


38.44 


38.57 


38.70 


38.83 


38.97 


39.10 


39.28 


39.36 


39.49 


30 


39.63 


39.76 


39.89 


40.02 


40.15 


40.29 


40.42 


40.55 


40.68 


40.81 



Urea. Table for a Temperature of 10° C 





1 


Vio 


Vio 


Vio 


Vio 


Vio 


Vio 


Vio 


8 /io 


Vio 


1 


1.31 


1.43 


1.56 


1.69 


1.82 


1.95 


2.08 


2.21 


2.34 


2.47 


2 


2.60 


2.73 


2.86 


2.99 


3.12 


3.25 


3.38 


3.51 


3.64 


3.77 


3 


3.90 


4.03 


4.16 


4.29 


4.42 


4.55 


4.68 


4.81 


4.94 


5.07 


4 


5.20 


5.33 


5.46 


5.59 


5.72 


5.85 


5.98 


6.11 


6.24 


6.37 


5 


6.50 


6.33 


6.76 


6.89 


7.02 


7.15 


7.28 


7.41 


7.-54 


7.67 


6 


7.80 


7.93 


8.06 


8.19 


8.32 


8.45 


8.58 


8.71 


8.84 


8.97 


7 


9.10 


9.23 


9.36 


9.49 


9.62 


9.75 


9.88 


10.01 


10.14 


10.27 


8 


10.40 


10.53 


10.66 


10.79 


10.92 


11.05 


11.18 


11.31 


11.44 


11.57 


9 


11.71 


11.84 


11.97 


12.10 


12.23 


12.36 


12.49 


12.62 


12.75 


12.88 


10 


13.01 


13.14 


13.27 


13.40 


13.53 


13.66 


13.79 


13.92 


14.05 


14.18 


11 


14.30 


14.44 


14.57 


14.70 


14.83 


14.95 


15.09 


15.22 


15.35 


15.48 


12 


15.60 


15.74 


15.87 


16.00 


16.13 


16.26 


16.39 


16.52 


16.65 


16.78 


13 


16.91 


17.04 


17.17 


17.30 


17.43 


17.56 


17.69 


17.82 


17.95 


18.08 


14 


18.21 


18.34 


18.47 


18.60 


18.73 


18.86 


18.99 


19.12 


19.25 


19.38 


15 


19.51 


19.64 


19.77 


19.90 


20.03 


20.16 


20.29 


20.42 


20.55 


20.68 


16 


20.81 


20.94 


21.07 


21.20 


21.33 


21.46 


21.59 


21.72 


21.85 


21.98 


17 


22.11 


22.24 


22.37 


22.50 


22.63 


22.76 


22.89 


23.02 


23.15 


23.28 


18 


23.41 


23.54 


23.67 


23.80 


23.93 


24.06 


24.19 


24.32 


24.45 


24.58 


19 


24.72 


24.85 


24.98 


25.11 


25.24 


25.37 


25.50 


25.63 


25.76 


25.89 


20 


26.02 


26.15 


26.28 


26.41 


26.54 


26.67 


26.80 


26.93 


27.06 


27.19 


21 


27.32 


27.45 


27.58 


27.71 


27.84 


27.97 


28.10 


28.23 


28.36 


28.49 


22 


28.62 


28.75 


28.88 


29.01 


29.14 


29.27 


29.40 


29.53 


29.66 


29.79 


23 


29.92 


30.05 


30.18 


30.31 


30.44 


30.57 


30.70 


30.83 


30.96 


31.09 


24 


31.22 


31.35 


31.48 


31.61 


31.74 


31.87 


32.00 


32.13 


32.26 


32.39 


25 


32.52 


32.65 


32.78 


32.91 


33.04 


33.17 


33.30 


33.43 


33.56 


33.69 


26 


33.82 


33.95 


34.08 


34.21 


34.34 


34.47 


34.60 


34.73 


34.86 


34.99 


27 


35.12 


35.25 


35.38 


35.51 


35.64 


35.77 


35.90 


36.03 


36.16 


36.29 


28 


36.42 


36.55 


36.68 


36.81 


36.94 


37.07 


37.20 


37.33 


37.46 


37.59 


29 


37.73 


37.86 


37.99 


38.12 


38.25 


38.38 


38.51 


38.64 


38.77 


38.90 


30 


39.03 


39.16 


39.29 


39.42 


39.55 


39.68 


39.81 


39.94 


40.07 


40.20 



THE CHEMISTRY OF THE URINE. 



337 



Urea. Table for a Temperature op 15° C. 





1 


Vio 


7io 


Vio 


Vio 


Vio 


Vio 


Vio 


Vio 


9/ 

/io 


1 


1.28 


1.41 


1.53 


1.66 


1.79 


1.92 


2.04 


2.17 


2.30 


2 43 


2 


2.56 


2.69 


2.81 


2.94 


3.07 


3.20 


3.33 


3.46 


3.58 


3^71 


3 


3.84 


3.97 


4.10 


4.22 


4.35 


4.48 


4.61 


4.74 


4.87 


4.99 


4 


5.12 


5.25 


5.38 


5.50 


5.63 


5.76 


5.89 


6.02 


6.14 


6.27 


5 


6.40 


6.53 


6.60 


6.79 


6.91 


7.04 


7.17 


7.30 


7.43 


7.55 


6 


7.68 


7.81 


7.94 


8.07 


8.19 


8.32 


8.45 


8.58 


8.71 


8.83 


7 


8.96 


9.09 


9.22 


9.35 


9.48 


9.60 


9.73 


9.86 


9.99 


10.12 


8 


10.24 


10.37 


10.50 


10.63 


10.76 


10.88 


11.01 


11.14 


11.27 


11.40 


9 


11.53 


11.65 


11.78 


11.91 


12.04 


12.17 


12.29 


12.42 


12.55 


12.68 


10 


12.81 


12.93 


13.06 


13.19 


13.32 


13.45 


13.57 


13.70 


13.83 


13.96 


11 


14.09 


14.22 


14.34 


14.47 


14.60 


14.73 


14.86 


14.98 


15.11 


15.24 


12 


15.37 


15.50 


15.62 


15.75 


15.88 


16.01 


16.14 


16.26 


16.39 


16.52 


13 


16.65 


16.78 


16.91 


17.03 


17.16 


17.29 


17.42 


17.55 


17.67 


17.80 


14 


17.93 


18.06 


18.19 


18.31 


18.44 


18.57 


18.70 


18.83 


18.95 


19.08 


15 


19.21 


19.34 


19.47 


19.60 


19.72 


19.85 


19.98 


20.11 


20.24 


20.36 


16 


20.49 


20.62 


20.75 


20.88 


21.00 


21.13 


21.26 


21.39 


21.52 


21.64 


17 


21.77 


21.90 


22.03 


22.16 


22.29 


22.41 


22.54 


22.67 


22.80 


22.93 


18 


23.05 


23.18 


23.31 


23.44 


23.57 


23.69 


23.82 


23.95 


24.08 


24.21 


19 


24.34 


24.46 


24.59 


24.72 


24.85 


24.98 


25.10 


25.23 


25.36 


25.49 


20 


25.62 


25.74 


25.87 


26.00 


26.13 


26.26 


26.38 


26.51 


26.64 


26.77 


21 


26.90 


27.03 


27.15 


27.28 


27.41 


27 54 


27.67 


27.79 


27.92 


28.05 


22 


28.18 


28.31 


28.43 


28.56 


28.69 


28.82 


28.95 


25.07 


29.20 


29.33 


23 


29.46 


29.59 


29.72 


29.84 


29.97 


30.10 


30.23 


30.36 


30.48 


30.61 


24 


30.74 


30.87 


31.00 


31.12 


31.25 


31.38 


31.51 


31.64 


31.76 


31.89 


25 


32.02 


32.15 


32.28 


32.41 


32.53 


32.66 


32.79 


32.92 


33.05 


33.17 


26 


33.30 


33.43 


33.56 


33.69 


33.81 


33.94 


34.07 


34.20 


34.33 


34.45 


27 


34.58 


34.71 


34.84 


34.97 


35.10 


35.42 


35.35 


35.48 


35.61 


35.74 


28 


35.86 


35.99 


36.12 


36.25 


36.38 


36.50 


36.63 


36.76 


36.89 


37.02 


29 


37.15 


37.27 


37.40 


37.53 


37.66 


37.79 


37.91 


38.04 


38.17 


38.30 


30 


38.43 


38.55 


38.68 


38.81 


38.94 


39.07 


39.12 


39.32 


39.45 


39.58 



Urea. Table for a Temperature of 20° C. 





1 


Vio 


v™_ 


3 /io 


Vio 


Vio 


Vio 


Vio 


Vio 


Vio 


1 


1.26 


1.38 


1.51 


1.63 


1.76 


1.89 


2.01 


2.14 


2.26 


2.39 


2 


2.52 


2.64 


2.77 


2.90 


3.02 


3.16 


3.27 


3.40 


3.53 


3.65 


3 


3.78 


3.91 


4.03 


4.16 


4.28 


4.41 


4.54 


4.66 


4.79 


4.91 


4 


5.04 


5.17 


5.29 


5.42 


5.54 


5.67 


5.80 


5.92 


6.05 


6.17 


5 


6.30 


6.43 


6.55 


6.68 


6.81 


6.93 


7.06 


7.18 


7.31 


7.44 


6 


7.56 


7.69 


7.81 


7.94 


8.07 


8.19 


8.32 


8.44 


8.57 


8.70 


7 


8.82 


8.95 


9.08 


9.20 


9.33 


9.45 


9.58 


9.71 


9.83 


9.96 


8 


10.08 


10.21 


10.34 


10.46 


10.59 


10.71 


10.84 


10.97 


11.09 


11.22 


9 


11.35 


11.47 


11.60 


11.72 


11.85 


11.98 


12.10 


12.23 


12.35 


12.4S 


10 


12.61 


12.73 


12.86 


12.98 


13.11 


13.24 


13.36 


13.49 


13.61 


13.74 


11 


13.87 


13.99 


14.12 


14.25 


14.37 


14.50 


14.62 


14.75 


14.8S 


15.00 


12 


15.13 


15.25 


15.38 


15.51 


15.63 


15.76 


15.88 


16.01 


16.14 


16.26 


13 


16.39 


16.52 


16.64 


16.77 


16.89 


17.02 


17.15 


17.27 


17.40 


17.52 


14 


17.65 


17.78 


17.90 


18.03 


18.15 


18.28 


18.41 


18.53 


18.66 


18.78 


15 


18.91 


19.04 


19.16 


19.29 


19.42 


19.54 


19.67 


19.79 


19.92 


20.05 


16 


20.17 


20.30 


20.42 


20.55 


20.68 


20.80 


20.93 


21.05 


21.18 


21.31 


17 


21.43 


21.56 


21.69 


21.81 


21.94 


22.06 


22.19 


22.32 


22.44 


22.57 


18 


22.69 


22.82 


22.95 


23.07 


23.20 


23.32 


23.45 


23.53 


23.70 


23.83 


19 


23.96 


24.08 


24.21 


24.33 


24.46 


24.59 


•J 1.71 


•J LSI 


21.96 


25.09 


20 


25.22 


25.34 


25.47 


25.59 


25.72 


25.85 


25.97 


26.10 


26.22 


26.85 


21 


26.48 


26.60 


26.73 


26.86 


26.98 


27.11 


27.23 


27.36 


27.49 


27.61 


22 


27.74 


27.86 


27.99 


28.12 


28.2 1 


2S.37 


28. 1'.' 


28.62 


28.75 


2S.S7 


23 


29.00 


29.13 


29.25 


29.38 


129.50 


29.63 


•2\). 76 


29.88 


30.01 


3.0.13 


24 


30.26 


30.39 


30.51 


30.64 


30.76 


30.89 


31.02 


31.14 


31.27 


81.89 


25 


31.52 


31.65 


31.77 


31.90 


32.03 


82.15 


32.28 


32,10 


32.53 


3.2.66 


26 


32.78 


32.91 


33.03 


33.16 


33.29 


33.41 


88.54 


88.66 


3.3.79 


33.92 


27 


34.04 


34.17 


34.30 


34.42 


34.55 


34.67 


3 I. SO 


31.93- 


35,05 


85.18 


28 


35.30 


;;;.. 13 


35.56 


35.68 


35.81 


35.98 


36.06 


36.19 


3.6.:; 1 


36.44 


29 


36.57 


36.69 


36.82 


36.94 


37.07 


37/20 


37.32 


87. 15 


87.57 


37.70 


30 


37.83 


37.95 


38.08 


38.20 


38.88 


38.46 


88.58 


38.71 


88.88 


88.96 



338 



THE URINE. 



Urea. Table foe, a Temperature of 25° C. 








Vio 


Vio 


Vio 


Vio 


Vio 


Vio 


Vio 


Vio 


Vio 


1 


1.24 


1.36 


1.49 


1.61 


1.73 


1.86 


1.98 


2.11 


2.23 


2.35 


2 


2.48 


2.60 


2.73 


2.85 


2.97 


3.10 


3 22 


3.35 


3.47 


3.59 


3 


3.72 


3.84 


3.97 


4.09 


4.22 


4.34 


4.46 


4.59 


4.71 


4.84 


4 


4.96 


5.08 


5.21 


5.33 


5.46 


5.58 


5.70 


5.83 


5.95 


6.08 


5 


6.20 


6.33 


6.45 


6.57 


6.70 


6.82 


6.95 


7.07 


7.19 


7.32 


6 


7.44 


7.57 


7.69 


7.81 


7.94 


8.06 


8.19 


8.31 


8.43 


8.50 


7 


8.68 


8.81 


8.93 


9.06 


9.18 


9.30 


9.43 


9.55 


9.68 


9.80 


8 


9.92 


10.05 


10.17 


10.30 


10.42 


10.. 54 


10.67 


10.79 


10.92 


10.04 


9 


11.17 


11.29 


11.41 


11.54 


11.66 


11.79 


11.91 


12.03 


12.16 


12.28 


10 


12.41 


12.53 


12.65 


12.78 


12.90 


13.03 


13.15 


13.27 


13.40 


13.52 


11 


13.65 


13.77 


13.89 


14.02 


14.14 


14.27 


14.39 


14.52 


14.64 


14.76 


12 


14.89 


15.01 


15.14 


15.26 


15.38 


15.51 


15.63 


15.76 


15.88 


16.00 


13 


16.13 


16.25 


16.38 


16.50 


16.63 


16.75 


16.87 


17.00 


17.12 


17.26 


14 


17.37 


17.49 


17.62 


17.74 


17.87 


17.99 


18.11 


18.24 


18.36 


18.49 


15 


18.61 


18.74 


18.86 


18.98 


19.11 


19.23 


19.36 


19.48 


19.60 


19.73 


16 


19.85 


19.98 


20.10 


20.22 


20.35 


20.47 


20.60 


20.72 


20.84 


20.97 


17 


21.09 


21.22 


21.34 


21.47 


21.59 


21.71 


21.84 


21.96 


22.09 


22.21 


18 


22.33 


22.46 


22.58 


22.71 


22.83 


22.95 


23.08 


23.20 


23.33 


23.45 


19 


23.58 


23.70 


23.82 


23.95 


24.07 


24.20 


24.32 


24.44 


24.57 


24.69 


20 


24.82 


24.94 


25.06 


25.19 


25.31 


25.44 


25.56 


25.68 


25.81 


25.93 


•21 


26.06 


26.18 


26.30 


26.43 


26.55 


26.68 


26.80 


26.92 


27.05 


27.17 


22 


27.30 


27.42 


27.55 


27.67 


27.79 


27.92 


28.04 


28.17 


28.29 


28.41 


23 


28.54 


28.66 


28.79 


28.91 


29.04 


29.16 


29.28 


29.41 


29.53 


29.66 


-24 


29.78 


29.90 


30.03 


30.15 


30.28 


30.40 


30.52 


30.65 


30.77 


30.90 


25 


31.02 


31.15 


31.27 


31.39 


31.52 


31.64 


31.77 


31.89 


32.01 


32.14 


26 


32.26 


32.39 


32.51 


32.63 


32.76 


32.88 


33.01 


33.13 


33.25 


33.38 


•27 


33.50 


33.63 


33.75 


33.88 


34.00 


34.12 


34.25 


34.37 


34.50 


34.62 


-28 


34.74 


34.87 


34.99 


35.12 


35.24 


35.36 


35.49 


35.61 


35.74 


35.86 


29 


35.99 


36.11 


36.23 


36.36 


36.48 


36.61 


36.73 


36.85 


36.98 


37.10 


30 


37.23 


37.35 


37.47 


37.60 


37.72 


37.85 


37.97 


38.09 


38.22 


38.24 



Urea. Table for a Temperature of 30° C. 








Vio 


2/ 
/10 


Vio 


Vio 


Vio 


Vio 


Vio 


Vio 


Vio 


1 


1.22 


1.34 


1.46 


1.58 


1.71 


1.83 


1.95 


2.07 


2.19 


2.32 


2 


2.44 


2.56 


2.68 


2.80 


2.93 


3.05 


3.17 


3.29 


3.41 


2.54 


3 


3.66 


3.78 


3.90 


4.03 


4.15 


4.77 


4.39 


4.51 


4.64 


4.76 


4 


4.88 


5.00 


5.12 


5.25 


5.37 


5.49 


5.61 


5.73 


5.86 


5.98 


5 


6.10 


6.22 


6.35 


6.47 


6.59 


6.71 


6.83 


6.96 


7.08 


7.20 


6 


7.32 


7.44 


7.57 


7.69 


7.81 


7.93 


8.05 


8.18 


8.30 


8.42 


7 


8.54 


8.67 


8.79 


8.91 


9.03 


9.15 


9.28 


9.40 


9.52 


9.64 


8 


9.76 


9.89 


10.01 


10.13 


10.25 


10.37 


10.50 


10.62 


10.74 


10.86 


9 


10.99 


11.11 


11.23 


11.35 


11.47 


11.60 


11.72 


11.84 


11.96 


12.08 


10 


12.21 


12.33 


12.45 


12.57 


12.69 


12.82 


12.94 


12.06 


13.18 


13.30 


11 


13.43 


13.55 


13.67 


13.79 


13.92 


14.04 


14.16 


14.28 


14.40 


14.53 


12 


14.65 


14.77 


14.89 


15.01 


15.14 


15.26 


15.38 


15.50 


15.62 


15.75 


13 


15.87 


15.99 


16.11 


16.24 


16.36 


16.48 


16.60 


16.72 


16.85 


16.97 


14 


17.09 


17.21 


17.33 


17.46 


17.58 


17.70 


17.82 


17.94 


18.07 


18.19 


15 


18.31 


18.43 


18.56 


18.68 


18.80 


18.92 


19.04 


19.17 


19.29 


19.41 


16 


19.53 


19.65 


19.78 


19.90 


20.02 


20.14 


20.26 


20.39 


20.51 


20.63 


17 


20.75 


20.88 


21.00 


21.12 


21.24 


21.36 


21.49 


21.61 


21.73 


21.85 


18 


21.97 


22.10 


22.22 


22.34 


22.46 


22.58 


22.71 


22.83 


22.95 


23.07 


19 


23.19 


23.32 


23.44 


23.56 


23.68 


23.81 


23.93 


24.05 


24.17 


24.29 


20 


24.42 


24.54 


24.66 


24.78 


24.90 


25.03 


25.15 


25.27 


25.39 


25.51 


21 


2o.65 


25.76 


25.88 


26.00 


26.13 


26.25 


26.37 


26.49 


26.61 


26.74 


22 


26.86 


26.98 


27.10 - 


27.22 


27.35 


27.47 


27.59 


27.71 


27.83 


27.96 


23 


28.08 


28.20 


28.32 


28.45 


28.57 


28.69 


28.81 


28.93 


29.06 


29.18 


24 


29.30 


29.42 


29.54 


29.67 


29.79 


29.91 


30.03 


30.15 


30.28 


30.40 


25 


30.52 


30.64 


30.77 


30.89 


31.01 


31.13 


31.25 


31.38 


31.50 


31.62 


26 


31.74 


31.86 


31.99 


32.11 


32.23 


32.35 


32.47 


32.60 


32.72 


32.84 


27 


32.96 


33.09 


33.21 


33.33 


33.45 


33.57 


33.70 


33.82 


33.94 


34.06 


28 


34.18 


34.31 


34.43 


34.55 


34.67 


34.79 


34.92 


35.04 


35.16 


35.28 


29 


35.41 


35.53 


35.65 


35.77 


35.89 


36.02 


36.14 


36.26 


36.38 


36.50 


30 


36.63 


36.75 


36.87 


36.99 


37.11 


37.24 


37.36 


37.48 


37.60 


37.72 



THE CHEMISTRY OF THE VBINE. 



Fig. 83. 



Of other forms of apparatus, the ureometers devised by Doremus, 
Green, Marshall, Hiiffner, and Squibb may be mentioned. 

The latest modification of Doremus' apparatus is certainly most 
convenient, and can be highly recommended. Its general construc- 
tion is seen in Fig. 83. A small amount of urine is poured into B 
while the stopcock (0) is closed. This is then opened for a moment 
and again closed, so as to fill its lumen. The tube (A) is washed 
out with water and filled with the hypobromite solution. The tube 
(B) is filled with urine, when 1 c.c. 
or less, if the urine is concentrated, 
is allowed to mix with the hypobro- 
mite solution in A. After all bub- 
bles of gas have disappeared the 
reading is taken. The degrees 
marked upon the tube indicate di- 
rectly the number of grammes or 
grains of urea, contained in the 
amount of urine employed. 1 

Green's apparatus (Fig. 84) con- 
sists of a tube, graduated in c.c, 
and blown out at the bottom into a 
wider portion, holding about 50 to 
60 c.c. The bulb is provided with 
a side-tube, into which a bent funnel- 
tube can be inserted for the purpose 
of equalizing the pressure. The 
side -tube having been detached, the 
apparatus is filled with sodium hypo- 
bromite solution, when 2 c.c. of 
urine, diluted if necessary, are intro- 
duced by means of a graduated and 
bent pipette. After all bubbles of 
gas have disappeared the funnel-tube 
is inserted into the side-opening and 
filled with hypobromite solution 
until the level in both tubes is the 
same. The volume is then noted, corrected, and the corresponding 
amount of urea calculated as described. 

Marshall's apparatus is a conveniently modified form of Green's, 
and is used in the same manner (Fig. 85). 

H'dfiner's apparatus is excellent (Fig. 86). It consists of a small 
bulb, A, of 5 c.c. capacity, which is separated from a larger bulb, 

1 Instead of employing the solution described on page 333, it is sufficient to till the 
long arm of the tube with a solution containing 100 grammes of caustic soda dissolved 
in 250 c.c. of distilled water, and to add 1 e.cOof bromine and a sufficient amount o( 
water to fill the bend of the tube. 




Doremns' ureonieter. 



340 



THE URINE. 



C, holding about 100 e.c, by a well-oiled glass stopcock. The 
upper end of C is drawn out to such an extent that the eudiometer 
T>, which is about 30 cm. long, 2 cm. wide, and divided into fifths 
of c.c, can be passed over it for a short distance. The bowl E, 
fitted over C by means of a cork, serves to hold a portion of the 
hypobromite solution. 

The exact capacity of A and of the lumen of the stopcock must 
be separately determined for each instrument. 

Method. — The bulb A and the lumen of the stopcock are filled 
with urine which has been diluted, if necessary. The stopcock 
having been closed, C is washed out carefully with 
distilled water and filled with the hypobromite solu- 
tion until the liquid in the dish stands several 
above the mouth of C. The eudiometer 



Fig. 86. 



cm 



is 



Fig. 84. 



Fig. 85. 





Green's ureometer. 



Marshall's ureometer. 



Hiiffner's ureometer. 



next filled with the same solution, carefully submerged in the liquid 
contained in the dish, and adjusted over the mouth of C. The 
urine in A is then allowed to mix with the hypobromite solution 
very gradually, by opening the stopcock. After all bubbles of gas 
have disappeared the eudiometer is transferred to a cylinder filled 
with water and thoroughly immersed. After twenty to thirty 
minutes the level of the liquid in the tube and that of the outside 
water are equalized and the reading taken. The temperature of 
the water being likewise noted, the volume of the gas is corrected 
and the corresponding amount of urea calculated. 



THE CHEMISTRY OF THE URINE. 341 

Squibb's Method. — This method, like that of Doremus, may be 
highly recommended to the practitioner for its simplicity. The ap- 
paratus (Fig. 87) consists of two ordinary medicine-bottles, A and 
B. In A the nitrogen is evolved. B is closed by a donbly perforated 
rubber-stopper, a straight tube passing through the upper aperture 
and connecting with the bottle A. Another tube, bent downward 
and carrying a clamp, as seen in the figure, leads to a graduated 
cylinder, E. B contains a sufficient amount of water for the bent 
tube to dip into ; 25 to 30 c.c. of the hypobromite solution, and a 
small tube containing 5 c.c. of urine, diluted if necessary, according 
to the specific gravity, are placed in A, the clamp at E being closed. 
The rubber-stopper is now firmly inserted and E opened, when a 
few drops of water, which may be disregarded, will escape. The 
graduated cylinder is then placed beneath the outflow-tube and the 
bottle A inclined. The nitrogen collecting in B displaces its own 

Fig. 87. 




Squibb's ureometer. 



volume of water, which flows out and is collected in E, whence the 
corresponding amount of urea may be calculated. 

It should be mentioned that sodium hypobromite liberates nitro- 
gen, not only from urea, but also from the other nitrogenous con- 
stituents of the urine ; the error thus incurred, however, appears 
just to counterbalance the deficit in the amount of nitrogen obtained, 
and corresponds to 1 gramme of urea. 

Estimation of Nitrogen. — For the purpose of estimating the total 
amount of nitrogen in the urine, the method of Kjeldahl or that of 
Will-Varrentrapp is most conveniently employed. 

Kjeldahl's Method: — Principle: The organic matter of the 
urine is decomposed by means of sulphuric acid, when all the nitrogen, 
which is not present in combination with oxygen, is transformed into 



342 



THE URINE. 



ammonia. After adding sodium hydrate in excess this is then dis- 
tilled off and received in a known quantity of titrated acid, the excess 
being retitrated with sodium hydrate. In this manner the amount 
of ammonia and the corresponding quantity of nitrogen is ascer- 
tained, it being remembered that 17 grammes of ammonia correspond 
to 14 grammes of nitrogen. 

Reagents required : 

1. Gunning's mixture. This consists of 15 c.c. of concentrated 
sulphuric acid, 10 grammes of potassium sulphate, and 0.5 gramme 
of copper sulphate. 

Fig. 88. 




Kjelclahl's nitrogen apparatus 



2. A solution of sodium hydrate containing 270 grammes in the 
litre (sp. gr. 1.243). 

3. Pulverized talcum or granulated zinc. 

4. A one-fourth normal solution of sulphuric acid. 

5. A one-fourth normal solution of sodium hydrate. 
Apparatus required (see Fig. 88). This consists of a retort of 

about 750 c.c. capacity (A), which is connected with a Kjeldahl dis- 
tilling tube (B), and through this with a Stadeler condenser (C). 
The ammonia is received in the nitrogen bulb at D. 



THE CHEMISTRY OF THE URINE. 343 

•In addition, a Kjeldahl digesting flask of 200 to 300 c.c. capacity 
is required. 

Method : 5 or 10 c.c. of urine are placed in the digesting flask 
and treated with Gunning's mixture. To this end it is best to add 
the sulphuric acid and copper sulphate first, to heat until sulphuric 
acid vapors are given off in abundance, and then to add the potas- 
sium sulphate. The heating is continued until the solution has be- 
come entirely clear and almost colorless, the flask being inclined to 
an angle of about 45°. Vigorous ebullition should be avoided. 

Upon cooling, the contents of the flask are transferred to the re- 
tort with the aid of a little water, and slowly treated with a moder- 
ate excess of the sodium hydrate solution. As a general rule, 40 c.c. 
for every 5 c.c. of sulphuric acid are sufficient. A little pulverized 
talcum, or a few pieces of granulated zinc are finally added, when 
the retort is connected with the condenser, and the distillation be- 
gun. This is continued until about two-thirds of the solution have 
passed over. The distillate is received in the nitrogen bulb, which 
should contain a carefully measured quantity of the one-fourth 
normal solution of sulphuric acid. As a general rule, 30 c.c. are 
sufficient. As soon as the distillation is completed the condenser 
is disconnected, washed out with a small amount of distilled water, 
and the washings added to the distillate. After the addition of a 
few drops of tincture of cochineal or dimethyl-amido-azo-benzol, 
the excess of sulphuric acid is then retitrated with the one-fourth 
normal solution of sodium hydrate, and the amount found deducted 
from the 30 c.c. used. The titration should be continued until every 
trace of yellow has disappeared and a pure rose-color is obtained, or 
in the case of the dimethyl-amido-benzol, until the last trace of red 
has disappeared and the solution has turned yellow. The difference 
multiplied with 0.0035 will then indicate the amount of nitrogen 
present in the 5 or 10 c.c. of urine. The corresponding amount of 
urea is found by multiplying this figure with 20. 

As Kjeldahl's method presupposes a thorough knowledge of 
chemical technique, it is well to make at least two parallel estimations 
in every case. 

Will-Varrentrapp's method, as modified by Seegen-Schneider. 
Principle : If nitrogenous organic material is heated in intimate 
contact with soda-lime, all the nitrogen is given off in the form of 
ammonia, which is collected in a known quantity of acid ; the excess. 
not used in the neutralization of the ammonia is then determined by 
titration with a solution of sodium hydrate of known strength. The 
amount held by the ammonia is thus ascertained, and from it the 
corresponding amount of nitrogen, it being remembered that 17 
grammes of ammonia correspond to 14 grammes of nitrogen. 

Reagents REQUIRED : 1. A quantity of thoroughly fused calcic 



344 



THE URINE. 



soda, which, while still hot, should be placed in a well-stoppered 
bottle, where it may be kept ready for use for a long time. 

2. A normal solution of sulphuric acid. 

3. A normal solution of sodium hydrate. 

Apparatus required: As is apparent from the accompanying diagram 
(Fig. 89), the apparatus consists of a Kjeldahl digesting flask, A, 
provided w T ith a long neck (10 to 12 cm. long), and of about 100 
c.c. capacity ; this is placed in a copper crucet, B, and imbedded in 
sand. The crucet is placed upon a pipe-stem triangle over the flame. 



Fig. 89. 




{#| "p 7" 


if 

1 





i 


i ! j : 

qiL.1 




^ 





Apparatus for the determination of nitrogen. 



The neck of the flask is surrounded by a hood of copper or tin plate, 
C, moulded to the flask and reaching not higher than 1.5 cm. below 
the rubber-stopper. The latter is doubly perforated, a tube, e, drawn 
out to a point and closed at the free end, passing through one aper- 
ture and extending about half-way down the flask, while the second 
passes through the other opening. This second tube, c, is connected 
by means of a short piece of rubber-tubing, upon which a clamp is 
placed, with a Will-Varrentrapp apparatus. The latter is connected 
by rubber-tubing, upon which a clamp is likewise placed, with an 
aspirating-bottle filled with water and provided with a siphon tube. 
Method : Ten c.c. of the normal sulphuric-acid solution are placed 
in the Will-Varrentrapp apparatus, together with a few c.c. of a 1- 



THE CHEMISTRY OF THE URINE. 345 

per-cent. solution of phenolphthalein. A layer of sand about 1 cm. 
in height is placed in the crucet, the clamp a closed, and the flask 
filled to about one-half its height with the soda-lime, when the hood 
is adjusted and 5 c.c. of urine are allowed to flow upon the soda. 
The rubber-stopper is quickly adjusted, the rubber tube having been 
previously connected with the Will-Varrentrapp apparatus. The 
clamp a is now opened, the crucet filled up with sand, and the heat- 
ing begun. This is at first done carefully with a small flame, but 
increased gradually until a full heat is applied. This is continued 
for one-half to three-quarters of an hour. When drops of moisture 
are no longer visible in the tube c, or when the evolution of gas has 
entirely ceased, the rubber-tube of the aspirating-bottle d is slipped 
on to the Will-Varrentrapp apparatus, the clamp b slightly opened, 
the tip of e broken off, and air allowed to pass slowly through the 
entire system for a quarter of an hour, when the flame is extinguished. 
The Will-Varrentrapp apparatus is then detached, and its contents 
titrated with the normal solution of sodium hydrate. 

The number of c.c. of the sodium hydrate solution employed is 
deducted from 10 (the number of c.c. of the normal sulphuric-acid 
solution, 1 c.c. of the latter being equivalent to 1 c.c. of the former), 
the difference giving the number of c.c. of the normal sulphuric-acid 
solution, neutralized by the ammonia, evolved from 5 c.c. of urine. 
This number multiplied by 20 will then represent the number of c.c. 
required to neutralize the ammonia contained in 100 c.c. of urine. 
As 1,000 c.c. of the normal solution of sulphuric acid correspond to 
17 grammes of ammonia or 14 grammes of nitrogen, the number of 
c.c. of the sulphuric-acid solution corresponding to 100 c.c. of urine 
will be found from the equation : 1,000 : 14 : : x : y, and y = 0.014 x, 
in which x represents the number of c.c. required to neutralize the 
amount of ammonia evolved from 100 c.c. of urine, and y the cor- 
responding amount of nitrogen — i. e., the percentage of nitrogen. 

If the nitrogen is to be calculated in terms of urea, this is done 
according to the equation : 1,000 : 30 (= 14N) : : x : y, and y = 
0.03 x = percentage of urea, in which x represents, as above, the 
number of c.c. of sulphuric acid neutralized by the ammonia, viz, 
nitrogen, contained in 100 c.c. of urine, and y the urea correspond- 
ing to this amount. 

Uric Acid. 

Uric acid, according to our present views, is not formed during 
the decomposition of all albuminous substances, as was formerly 
supposed, hut constitutes a specific product of decomposition of one 
class of albumins only, namely, the nucleins. It appears, moreover, 
that the mother substance of uric acid is confined to the nuclear 
nucleins, viz, to those containing a nucleinic acid radicle, while the 



346 



THE URINE. 



paranucleus, in which this is lacking, are without effect upon the 
elimination of uric acid. According to Kossel four different forms 
of nucleinic acid exist, viz, adenylic acid, guanylic acid, sarcylic 
acid and xanthylic acid, and the supposition is, that each of these con- 
tains one base, viz, adenin, guanin, sarcin, or hypoxanthin, and xan- 
thin. These basic substances are collectively spoken of as the 
xanthin, attoxur, or puriii bases. According to Emil Fischer they 
are derived from a hypothetical compound which he terms purin,. 
and which he supposes to be constituted as shown in the formula : 



(1) N= 

I 



(6) 
I 



;2)HC (6)C- 



(3) 1ST- 



(4) 



(7) 
-NR- 

(9) 



.CH(8). 



By substituting the group NH 2 for the H atom at 6, adenin thus 
results and is hence also spoken of as 6-aminopurin : 



N- 

I 
HC 



:C.XH, 

I 

II />CH 

-C N 



according to this conception, would be 6-oxypurin, 
anin, 2-amino-6-oxypurin, as shown 



Hypoxanthin, according to this co: 
xanthin 2, 6-dioxypurin, and guanin, 
by the structural formulae : 





Hypoxanthin. 






Xanthin. 


HN- 


—CO 




HN — 


-CO 


1 
HC 

II 
N— 


C NH\ 

II >H. 
— C N 

HN- 


Guanin 

— CO 

1 


1 
CO 

hJt- 


1 
C 1 

II 
-c — : 




HN=C 
HN- 


1 
c 

II 
— c — 


-NH X 

>CH 





NH^ 



V CH. 



From the structural formula of purin it is also apparent that still 
other derivatives of this substance may exist, and as a matter of 
fact others are known, viz, mono-methyl xanthin or hetero-xanthin, 
di-methylxanthin or paraxanthin, tri-methylxanthin, the isomeric 
compounds of paraxanthin, viz, theophyllin and theobromin, and 



others. Their relation to xanthin is shown in the formulas 



THE CHEMISTRY OF THE URINE. 347 

Xanthin. Heteroxanthin. Paraxanthin. 

HN CO HN CO CH 3 .N CO 

CO C NH X CO C N.CH 3 \ CO C N.CH sX 

I II ^CH. I || ^>CH. I || _^CH. 

HN C N/ HN C N- HN C N^=^ 

Theophyllin. Theobromin. 

CH 3 .N CO HN CO 

II II 
CO C NH X CO C N.CH 3X 

I II >CH. I || ^^CH. 

CH 3 .N C N CH 3 .N C N== 

Coffein. 

CH 3 .N CO 

I I 

CO C N.CH 3 \ 

I || '^ CH. 

CH 3 . N C K^ 

Two of these bodies, namely heteroxanthin and paraxanthin have 
also been found in the urine. 

From these basic substances then, which are found in the nuc- 
leinic acid radicle of the nuclear nucleins, uric acid is supposedly de- 
rived, and there are numerous facts which go to show that this sup- 
position is in all likelihood correct. It will thus be observed that 
structurally uric acid is intimately related to the bodies in question, 
and like these contains the purin radicle : 

Uric acid. 
HN CO 

CO C NH\ 

I II >co. 

HN C NH/ 

It may hence be regarded as 2, 6, 8 tri-oxypurin. Uric acid and 
the xanthin bases, moreover, qualitatively, all yield the same decom- 
position products, when treated with fuming hydrochloric acid or 
hydriotic acid, under high pressure ; only the quantitative relations 
vary, as shown in the equations : 

Adenin. Glycocoll. Formic acid. 

C 5 H 5 N 5 + 8H 2 = 4NH 3 + CO, + CH 2 .NH 2 .COOH + 2H.COOH. 

Hypoxan thin. 

C 5 H 4 N 4 -f 7H 2 = 3NH 3 + C0 2 + CH,NII 2 .COOII + 2H.COOH. 

Guanin. 

C 5 H 5 N 5 + 7H 2 = 4NH 3 + 2CO, -f CI I,. NIL. COO I I + H.COOH. 

Xanthin. 

C 5 H 4 N 4 2 + 6H 2 = 3NH 3 -f 2CO a + CIL.NIL.COOII + H.COOH. 

Uric acid. 

C 5 ir,N 4 3 + 5II 2 = 3NH 8 + 3<X> a +CH a .NH a .COOH. 



348 THE URINE. 

In accordance with this supposed origin of uric acid we find an 
increased elimination in the urine, following the ingestion of all 
those substances which either contain purin bases as such, or in the 
form of nuclear nucleins. At the same time it must be remembered 
that uric acid can also result from the nucleins of the body tissues, 
and we find, as a matter of fact, that during starvation the uric acid 
does not disappear from the urine. The principal source of the uric 
acid under such conditions are the nucleins of the leucocytes, and 
according to Horbaczewski and others this source is indeed more 
important than the nucleins of the food. According to his idea the 
latter only call forth an increased elimination of uric acid in an in- 
direct manner, i. e., by stimulating more strongly than other food- 
stuffs the cell formation and cell destruction of the body. However 
this may be, there can be no doubt that the amount of uric acid 
eliminated in the urine depends, in the first instance, upon the amount 
of nucleins or purin bases as such, which are ingested, and upon the 
degree of nuclear destruction which takes place in the body. Other 
factors, however, also enter into consideration. We thus know that 
the body is capable of transforming a certain amount of uric acid 
into urea. This fact was pointed out long ago by Frerichs and 
Wohler, and has recently again been confirmed. It was found that 
after the ingestion of large amounts of nucleins, only a certain por- 
tion of the nuclear nitrogen is eliminated as uric acid, and that this 
portion is extremely variable. Whether individual peculiarities play 
a part in determining this amount is unknown, but not improbable. 
The power of oxidation on the part of the body tissues, however, 
must also be taken into consideration, and unquestionably varies not 
only in different people, but also in one and the same individual. 
Then again there is evidence to show that under certain conditions 
uric acid may also be formed synthetically in the body. That this 
is the usual mode of formation in birds and reptiles has been con- 
clusively shown by Minkowski, who found that after extirpation of 
the liver in geese the greater portion of the urinary nitrogen was 
eliminated in the form of ammonia in combination with lactic acid. 
In the human being very little uric acid is in all likelihood formed 
in this manner under normal conditions, but the possibility of its 
occurrence, in disease more particularly, cannot be overlooked. 

As uric acid, moreover, may in part at least be eliminated in the 
feces, it is clear that the amount, which is eliminated in the urine 
cannot be regarded as an infallible index of the degree of nuclear 
destruction, or of the amount which is formed in the body-tissues. 
That a retention of uric acid can further occur in the body, which 
may or may not be followed by an increased elimination is likewise 
undoubted. 

The conditions which thus influence the formation and elimination 



THE CHEMISTRY OF THE URINE. 349 

of uric acid are quite complicated;, aud it will be readily understood 
that, even under normal and apparently identical conditions, the 
amount which is daily eliminated must be subject to fairly wide varia- 
tion. A pathologic alteration of the conditions which give rise to its 
formation and elimination can only be assumed when the amount, 
which is eliminated in the twenty-four hours, falls short of the 
physiologic minimum, or exceeds the usual upper limit, viz, 0.2 and 
1 .5 grammes respectively. 

The place of formation of uric acid in man is as yet unknown. 
According to some observers it is formed in all the organs of the 
body, including the bone-marrow, the muscles, the liver, the spleen, 
the gouty joints, etc., but this view, as well as that expressed by 
Kolisch and Luff, according to which the kidneys form uric acid 
from the xanthin bases, still remains unsupported by material 
facts. 

Under normal conditions, as I have just said, the daily elimination of 
uric acid varies between 0.2 and 1.5 grammes, thus constituting the 
^tq—jj-q part of the total urinary nitrogen. It is largely influenced by 
the character of the diet, the amount of exercise taken, the general 
health of the individual, etc. After the ingestion of large amounts 
of food, which is rich in nuclear nucleins, such as thymus gland, 
liver, kidneys and brain, a corresponding increase in the amount of 
uric acid is observed. Generally speaking animal food causes a 
greater elimination of uric acid than vegetable food, and it is sup- 
posed that this difference is essentially due to the presence of the 
extractives of the meat. Of special interest is the increase in the 
elimination of uric acid, which is observed five hours after the in- 
gestion of a full meal. This increase, according to Horbaczewski, 
is associated with the disappearance of the digestive leucocytosis and 
consequent leucolysis. 

Some observers have attached much importance to the relation 
existing between the elimination of uric acid and urea, and are in- 
clined to assume the existence of a special uric acid diathesis when 
this relation continuously exceeds the usual standard of 1 : 50 or 1 : 60. 
This question is, however, an extremely intricate one, and we are 
scarcely in a position at the present time to speak definitely of the 
significance of such variations. On the one hand, there can be no 
doubt that an unusually high uric acid coefficient may be met with 
in individuals who are apparently in good health, while in others, 
where larger amounts of uric acid are eliminated than is usual, normal 
or even subnormal values may be found. The entire question of the 
uric acid diathesis is indeed in a most chaotic condition, and it would 
perhaps be well to speak of such a diathesis only, when a distinct 
absolute increase is continuously observed. That numerous symptoms 
of a neurasthenic type are often seen, when the uric acid coefficient is 



350 THE URINE. 

increased, is a matter of daily observation, but it would be premature 
to regard this symptom as a causative factor of the disease in ques- 
tion. Even in gout it can scarcely be said that uric acid has been 
proven the materia peccans, and our knowledge concerning its etiology 
is still as obscure as at the time when Garrod first showed that an 
accumulation of uric acid occurred in the blood of such patients. 
Hitherto it has been supposed that the deposition of urates in the 
joints and periosteum of gouty patients was referable to a diminished 
alkalinity of the blood, and that the acute paroxysms resulted when- 
ever an increase in its alkalinity occurred, leading to a resorption of 
the uric acid, previously deposited, and a consequent flooding of the 
system with the substance in question. As a matter of fact a con- 
siderable diminution in its excretion is observed immediately pre- 
ceding the attack, while during the paroxysm and immediately 
following it, a corresponding increase is noted. Numerous investi- 
gations, however, have shown that distinct changes in the alkalinity 
of the blood do not occur in gout, and that an increase in the amount 
of uric acid in the blood is not only observed in this disease, but in 
other diseases as well, which are not associated with gouty symptoms. 
The conclusion is hence justifiable, that the presence of uric acid in 
the blood, per se, cannot be offered as an explanation of the occur- 
rence of a gouty attack. 

The greatest increase in the elimination of uric acid is observed 
in leukaemia, where amounts of 5 grammes and even more may be 
observed in the twenty-four hours. That the increased elimination 
in this disease is referable to the enormous increase in the number of 
the leucocytes, and consequent leucolysis can scarcely be doubted. 
In other diseases, which are associated with a high grade of leuco- 
cytosis, and especially those, in which the disease terminates by crisis 
or hastened lysis, such as erysipelas and pneumonia, a considerable 
increase is likewise observed, and referable to the same origin. This 
increase is especially marked immediately after crisis has occurred, 
but it not infrequently precedes this by several hours. In the other 
febrile diseases an absolute increase is less marked and inconstant. 

In diabetes a diminished amount of uric acid is usually found. 
Cases may be seen, however, in which, associated with a diminution 
or an entire disappearance of the sugar, a most marked increase 
occurs, amounting in some cases to three grammes in the twenty-four 
hours. To this condition the term diabetes alternans has been applied. 

In acute articular rheumatism an increased elimination is ob- 
served so long as the temperature remains high, while with approach- 
ing convalescence the amount returns to normal and may even fall 
below normal. In chronic rheumatism, on the other hand, no constant 
relations have been observed. In the ordinary forms of anaemia 
and chlorosis the amount of uric acid is quite constantly diminished, 



THE CHEMISTRY OF THE URINE. 351 

as also in chronic interstitial nephritis, chronic lead-poisoning, pro- 
gressive muscular atrophy and pseudo-hypertrophic paralysis. 

Properties of Uric Acid. — The close relation existing between 
uric acid and the xanthin bases has already been considered. By 
oxidation uric acid is transformed into urea or into substituted ureas, 
such as allantoin and alloxan, which latter in turn is closely related 
to parabanic acid, or oxalyl-urea, and barbituric acid or malonyl- 
urea. 

Alloxan. 
Uric acid. CO NH. Urea 

C 5 H 4 N 4 O s + + H,0=| ■ 

CO \ CO 4 co <£S 2 • 

rsxi 2 
CO OH 

Uric acid. Allantonm. 

C 5 H 4 N 4 3 4 H 2 = C 4 H 6 N A 4 C0 2 . 

Pure uric acid forms a white, crystalline powder, which is almost 
insoluble in cold water (1 : 40,000), with difficulty soluble in boiling 
water (1 : 1,800), and insoluble in alcohol and ether. In concentrated 
sulphuric acid it dissolves with ease, but is reprecipitated upon dilu- 
tion with water. In aqueous solutions of the alkaline carbonates 
and hydrates it dissolves, with the formation of neutral or acid salts, 
as represented by the equations : 

C 5 H 4 N 4 3 4 Na^COs = C 5 H 3 Nal$ 4 3 4 NaHC0 3 . 

C 5 H 4 N 4 3 4 2Na2C0 3 = C 5 H 2 Na 2 N 4 3 4- 2NaHC0 3 . 

In the urine uric acid is said to occur as a quadriurate, viz, as a 
compound, in which one molecule of sodium is in combination with 
two molecules of uric acid. The quadriurate, however, is readily 
decomposed with the formation of uric acid and acid urates (biurates). 
Its solubility in the urine depends upon the amount of water present, 
the reaction, and the presence of inorganic salts. When acid sodium 
phosphate preponderates the biurate is precipitated, while free uric 
acid is thrown down when disodic phosphate only is present, and 
along with this still other acid compounds, which are most likely of 
organic nature. Neutral urates cannot occur in the urine. The 
basic substances, which may occur in the urine in combination with 
uric acid are sodium, potassium, ammonium, and possibly also calcium 
and magnesium. These salts may be decomposed by the addition of 
a sufficiently large quantity of a stronger acid, such as hydrochloric 
acid, when uric acid is set free. All these salts are soluble with 
great difficulty, and are hence precipitated, whenever the urine is 
markedly acid or concentrated, and also when it is exposed to a low 
temperature. This holds good especially for the aeid ammonium 
compound, and upon this fact Hopkin's quantitative estimation of 
uric acid is based. 



352 



THE URINE. 



Pure uric acid crystallizes in transparent, colorless, rhombic plates, 
while that which usually separates from the urine is of a reddish- 
brown color and may assume a great variety of forms (Fig. 90). Of 
these the so-called whetstone form is the most characteristic (see 
Sediments). Colorless rhombic platelets may, however, also be seen. 

Of the compound which uric acid forms with the heavy metals, 
the silver salt is especially important. When a solution of uric acid 
in ammonia is treated with an ammoniacal solution of silver nitrate 
(see below) the solution remains clear, but if calcium chloride, sodium 
chloride or magnesia mixture is then added, a precipitate forms, 
which contains the uric acid in combination with silver. 

Tests for Uric Acid. — 1. Murexid Test. — A few crystals are dis- 
solved by means of a few drops of concentrated nitric acid, with the 



Fig. 90. 







^ 




o 



^ p 







V, 

A 

Various forms of uric-acid crystals. (Finlayson. ) 

application of heat, upon a porcelain plate, such as the cover of a 
crucible. The nitric acid is then carefully evaporated, when a yel- 
lowish-red spot will be found to remain. Upon cooling, a drop of 
ammonia is placed upon this spot, when in the presence of uric acid 
a beautiful purplish-red color will develop, owing to the formation 
of ammonium purpurate (murexid). If now a drop of sodium 
hydrate solution is added, the color will change to a reddish-blue, 
which disappears upon heating, thus differing from the somewhat 
similar xanthin reaction. 

2. Copper Test. — A few crystals are dissolved in sodium hydrate 
solution and treated with a few drops of Fehling's solution. Upon 
the application of heat white urate of copper separates oat, while red 
cuprous oxide appears, if a relatively large amount of copper sulphate 



THE CHEMISTRY OF THE URINE. 353 

is present, — a point to be remembered in testing for sugar. The 
reduction of Fehling's solution is due to the formation of allantoin. 
3. When treated with sodium hypobromite solution uric acid gives 
up about 47 per cent, of its nitrogen. 

Quantitative Estimation of Uric Acid. 

Hopkins' Method. — This method is now quite commonly used in 
the clinical laboratory, and is certainly to be preferred to the more 
complicated procedures, which have hitherto been employed. It is 
much simpler and fully as accurate as the older methods of Ludwig- 
Salkowski and of Haycraft. Various modifications of the original 
method have been suggested. 

Principle : The method is based upon the complete precipitation 
of uric acid by ammonium salts, and the possibility of accurately 
titrating the uric acid with potassium permanganate, in the presence 
of sulphuric acid. 

Folios Modification of Hopkins' Method : 50 c.c. of urine 
are treated with 5 grms. of finely powdered ammonium carbonate, 
acetate, chloride or sulphate, and a sufficient amount of ammonia, to 
render the mixture faintly, but distinctly alkaline. After standing 
for 2 hours, the precipitated mono-ammonium urate is filtered oif 
through asbestos, or paper No. 597 of Schleicher and Schull, washed 
with a 10-per-cent. solution of ammonium sulphate, until all 
chlorides have been removed, and transferred to a beaker with the 
aid of 100 c.c. of hot water, by perforating the filter. The urate is 
then decomposed by the addition of a small amount of dilute sul- 
phuric acid. On cooling to about 20°C. 15 c.c. of concentrated sul- 
phuric acid (sp. gr. 1.84) are added, when the mixture is titrated at 
once with a 1/20 normal solution of potassium permanganate, until a 
faint red color is obtained, which persists for at least 30 seconds. 
The number of cubic centimetres employed to reach this end is multi- 
plied with the empirical factor 0.00375, the result indicating the 
amount of uric acid in 50 c.c. of urine. As 0.001 grm. of uric acid, 
however, escapes precipitation in every 100 c.c. of urine, it is neces- 
sary to add 0.0005 grm. to the final result. 

Preparation of the 1/20 normal solution of potassium perman- 
ganate : As the molecular weight of potassium permanganate is 
157.67 one would expect that a normal solution of the salt should 
contain this amouut in grammes, dissolved in 1,000 c.c. of water. 
But the substance generally acts in the presence of free acids, upon 
deoxidizing substances, by loosing five atoms of oxygen, of the eight 
atoms contained in two molecules, as is shown in the following equa- 
tion : 

2KMn(), -f 5H 2 C a 4 + 3H a SO, = K,sO t + 2MnSO< 4- l0CO s -f 8H..O. 
23 



354 THE URINE. 

It follows that two-fifths of the molecular weight, or 63.068 grins, 
are the equivalent of one oxygen atom. But as oxygen is diatomic 
and the volumetric normal is calculated for monatomic values, this 
number must be divided by two, and 31.534 grms. of potassium 
permanganate is therefore the amount to furnish one litre of normal 
solution (W. Simon). A 1/10 normal solution would hence contain 
3.1534 grms., and a 1/20 normal solution 1.576 grms. pro litre. 
This amount is weighed off and dissolved in 950 c.c. of water, when 
the solution is brought to the proper degree of dilution (see p. 300) 
by titration with a 1/20 normal solution of oxalic acid. A 1/20 
normal solution of oxalic acid contains 3.142 grms. of the acid in 
1,000 c.c. of water. 1 c.c. of the 1/20 normal solution of potassium 
permanganate should correspond to 1 c.c. of the oxalic-acid solution. 
The titration is best conducted by diluting 1 c.c. of the oxalic-acid 
solution to 100 c.c. with distilled water and adding 15 c.c. of con- 
centrated sulphuric acid, so as to bring the temperature of the liquid 
to from .55— 65 °C. The potassium permanganate solution is then 
added drop by drop until the red color no longer disappears on 
stirring, but persists for at least 30 seconds. 

Titration with Sodium Hydrate Solution. — This method 
is in some respects more convenient than the one just described and 
also furnishes fairly accurate results. The uric acid is precipitated 
with an ammonium salt, as above. After standing for two hours the 
ammonium urate is filtered off, washed with a 10-per-cent. solution 
of ammonium sulphate and brought into a beaker with the aid of a 
small amount of hot water. The salt is then decomposed by the 
addition of from 10-15 c.c. of a 1/10 normal solution of hydro- 
chloric acid. The mixture is brought to the boiling point, and the 
hydrochloric acid not used in the decomposition of the ammonium 
urate, retitrated with a 1/10 normal solution of sodium hydrate, using 
dimethyl-amido-azo-benzol as an indicator. The amount of hydro- 
chloric acid found is deducted from the 10 or 15 c.c. added, and the 
result multiplied with 0.0168. The amount of uric acid contained 
in the original quantity of urine is thus ascertained, to which 0.0005 
grm. is added for every 50 c.c. of urine used, to allow for the trace 
of uric acid, which is not precipitated by the ammonium salt. 

Gravimetric Method. — The process is begun as described above. 
The ammonium urate is decomposed by the addition of from 2—3 
c.c. of a 25-per-cent. solution of hydrochloric acid. This solution 
is evaporated until crystals of uric acid begin to separate out. These 
are then collected on a dried and weighed filter, and washed succes- 
sively, with water, alcohol (90-95-per-cent.), absolute alcohol and 
finally with ether. The mother-liquor and water used in washing 
are carefully measured, and 0.0004 grm. added to the final result, 
for every 10 c.c. 



THE CHEMISTRY OF THE URINE. 355 

Hay craft's Method. — This method is based upon the precipitation 
of uric acid with an ammoniacal silver solution and magnesia mix- 
ture, 1 molecule of silver corresponding to 1 molecule of uric acid. 
As the amount of silver thus precipitated can be determined by titra- 
tion with a solution of potassium sulpho-cyanide, the corresponding 
amount of uric acid is readily found. 

Solutions required : 1. An ammoniacal silver solution. 2. An 
ammoniacal magnesia mixture. 3. A one-fiftieth normal solution of 
nitrate of silver. 4. A one-fiftieth normal solution of potassium 
sulpho-cyanide. 

Preparation of these solutions : 

1. The ammoniacal silver solution is prepared by dissolving 26 
grammes of nitrate of silver in distilled water, and adding enough 
ammonia to redissolve the brown precipitate of oxide of silver, which is 
first formed ; distilled water is then added in sufficient amount to make 
the total quantity 950 c.c. This solution is brought to the proper 
strength by titrating a known amount of sodium chloride, as de- 
scribed elsewdiere. Each c.c. then contains 0.026 gramme of nitrate 
of silver, which is equivalent to 0.00216 gramme of silver. 

2. The ammoniacal magnesia mixture is prepared by dissolving 
100 grammes of crystallized magnesium chloride in a sufficient 
amount of water ; to this a cold saturated solution of ammonium 
chloride is added in excess, and enough strong ammonia to impart a 
decided odor. Should the mixture not be perfectly clear, still more 
ammonium chloride solutiou is added. The solution is then diluted 
with water to one litre. 

3. The one-fiftieth normal solution of nitrate of silver is prepared 
by dissolving 3.4 grammes of silver nitrate in 950 c.c. of distilled 
water, the degree of further dilution being determined as described 
elsewhere. 

4. To prepare the one-fiftieth normal solution of potassium sulpho- 
cyanide, about 2 grammes of the salt are dissolved in 950 c.c. of 
water and the solution brought to the required strength, so that 1 
c.c. shall correspond to 1 c.c. of the silver solution. 

For filtering the uric acid a perforated platinum cone is placed in 
a small funnel and packed with a fine layer of glass-wool, upon 
which, in turn, a layer of finely scraped asbestos is placed. The 
asbestos is previously thoroughly washed with very dilute hydro- 
chloric acid and subsequently with distilled water until every trace 
of chlorine has disappeared. When properly prepared the asbestos 
forms a mould of the cone. 

Method. — Five c.c. of t\\c ammoniacal silver solutiou are mixed 
with 5 c.c. of the ammoniacal magnesia mixture. Ammonia is then 
added until the solution is clear, when it is poured into 50 c.c. of 
urine. As soon as the precipitate has settled the supernatant liquid 



356 THE URINE. 

is passed through the prepared filter with the aid of a suction-pump. 
About 4 grammes of sodium bicarbonate in coarse pieces are now 
placed upon the filter and the precipitate added ; the sodium bicar- 
bonate serves the purpose of aiding filtration by loosening the pre- 
cipitate. This is now r washed free from chlorine and silver by means 
of ammoniacal water, using the suction-pump, until the precipitate 
appears broken in places, then without the pump, using this only at 
last to remove the last drops of liquid. Test for silver with very 
dilute hydrochloric acid, and for chlorine with a solution of nitrate of 
silver and nitric acid. The precipitate thus obtained is dissolved on 
the filter by means of nitric acid of 20 to 30 per cent. The nitric 
acid must be free from nitrous acid. This is secured by al- 
lowing it to stand in contact with pure urea until all evolution of 
gas has ceased. The filter is washed with very dilute nitric acid 
and then with distilled water, until this no longer shows an acid re- 
action. The solution thus obtained is titrated with the one-fiftieth 
normal solution of potassium sulpho-cyanide, using ammonio-ferric 
alum as an indicator. As every c.c. of this solution indicates 0.00216 
gramme of silver, and as 1 molecule of silver indicates 1 mole- 
cule of uric acid — i. e., 108 grammes of silver 168 grammes of uric 
acid, — 0.00216 gramme of silver, corresponding to 1 c.c. of the po- 
tassium sulpho-cyanide solution, represents 0.00336 gramme of uric 
acid. 

Ludwig-Salkowski Method. — Principle : A solution of uric 
acid in sodium carbonate, when treated with a solution of nitrate of 
silver, after the previous addition of an excess of ammonia, gives 
rise to a flaky, gelatinous precipitate consisting of uric acid, sodium, 
and silver, which is soluble with great difficulty. From this the 
silver may be removed, when the compound of uric acid and sodium 
is decomposed by means of hydrochloric acid. 

Method. — Two hundred and fifty c.c. of urine are treated with 50 
c.c. of ammoniacal magnesia mixture (see above) for the purpose 
of removing the phosphates. The magnesia mixture is employed 
for the reason that the compound of uric acid with magnesium and 
silver which is formed later on is not decomposed so easily as the 
sodium or the potassium compound, which would occur if the urine 
were only precipitated with ammonia. The mixture is then imme- 
diately filtered, as otherwise a little magnesium urate would be pre- 
cipitated. 250 c.c. of the filtrate, corresponding to 200 c.c. of urine, 
are measured off, as soon as possible, and treated with a few c.c. of 
a 3-per-cent. solution of nitrate of silver. If the precipitated silver 
chloride, formed' in the beginning, does not disappear on stirring, a 
little more ammonium hydrate is added. A flaky precipitate next 
separates out, and is allowed to settle. In order to test whether 
enough of the silver nitrate solution has been added, a few c.c. of the 



THE CHEMISTRY OF THE URINE. 357 

supernatant fluid are acidified with nitric acid. If a distinct cloudi- 
ness, referable to silver chloride appears, enough has been added. 
Otherwise the few c.c. that were employed for this test are rendered 
alkaline again with ammonia, poured back, and treated with more 
silver solution until the required amount has been reached. The liquid 
is then rapidly filtered through a folded filter of rather loose paper, a 
feather or rubber-tipped glass rod being used for the purpose of re- 
moving all the precipitate from the beaker. The precipitate is 
washed, until a specimen of the washings is no longer rendered tur- 
bid by nitric acid, and only faintly so by the addition of a drop of 
silver solution. The filter with the precipitate is next placed in a 
wide-mouthed flask, containing about 200 c.c. of distilled water, and 
thoroughly agitated. Sulphuretted hydrogen is then passed through 
the mixture. It is now brought to the boiling-point and rendered dis- 
tinctly acid by means of a few drops of hydrochloric acid, when the 
sulphide of silver and the paper are rapidly filtered off, as otherwise 
there will be an admixture of sulphur to the uric acid. The con- 
tents of the filter are washed a few times with hot water. Filtrate 
and washings are quickly evaporated to a few c.c, treated with a few 
drops of hydrochloric acid, and set aside in a cool place for twenty- 
four hours. Occasionally it happens that upon the addition of the 
hydrochloric acid a cloudiness appears, which is due to an admixture 
of sulphur. In such a case the dried uric acid must be washed with 
carbon disulphide. Otherwise the uric acid that has separated out is 
directly collected on a dried and weighed filter, and washed succes- 
sively with water, 90- to 94-per-cent. alcohol, and finally with abso- 
lute alcohol and ether. The water used in washing should be col- 
lected separately, and 0.0048 gramme added to the weight of the 
uric acid obtained, for every 20 c.c. used. 

Precautions : 1. Rapidity in working is essential. 

2. Very concentrated urines must be diluted one-half before com- 
mencing the examination. 

3. If the specific gravity of the urine is low, it should be con- 
centrated to a specific gravity of about 1.020. 

4. If the urine shows a sediment of uric acid, this should be sepa- 
rately collected and weighed, and the weight obtained added to the 
final result. 

5. Any albumin that may be present must be previously removed. 

6. If sugar is present in the urine, about 500 to 1,000 c.c. are 
treated with a solution of neutral acetate of lead, filtered, and the 
filtrate precipitated with mercuric acetate. The precipitate thus 
formed, which consists essentially of mercuric urate, is filtered off 
after having stood for twelve to twenty-four hours, then washed and 
later suspended in water. The mercury is removed by means of 
sulphuretted hydrogen, the sulphide of mercury filtered off, and the 



358 THE URINE. 

filtrate collected and set aside. The precipitate itself is thoroughly 
boiled with Avater and again filtered, the washings thus obtained 
being added to the filtrate set aside, as just described. The total 
amount of fluid is then evaporated to a small volume and acidified 
with hydrochloric acid, when the uric acid will separate out and may 
be treated as previously directed. 

The Old Method of Heintz. — The following method, although inac- 
curate, may be employed when the necessary solutions required for 
more accurate working are not at hand : 

Principle : The urates contained in the urine are decomposed by 
means of hydrochloric acid, the uric acid formed being set free. 

Method : Two hundred c.c. of urine are treated with 10 c.c. of 
strong hydrochloric acid and set aside, in a cool place, for forty- 
eight hours. The crystals of uric acid which have been deposited 
by that time are collected on a small filter that has been dried at a 
temperature of 110° to 115°C, and carefully weighed, using a cut 
feather or a rubber-tipped glass rod to remove all the crystals from 

Fig. 91. 




Watch crystals. (W. Simon. ) 

the bottom and sides of the vessel ; portions of the filtrate are used 
to bring the last traces upon the filter. The crystals are then washed 
with cold water, care being taken to collect the washings separately, 
until a specimen no longer becomes cloudy, when treated with a few 
drops of nitrate of silver and nitric acid. Funnel and filter are then 
dried in the hot-air bath at a temperature of 110° to 115°C, and 
the filter finally dried to a constant weight at the same temperature. 
The filter is most conveniently dried between watch glasses (Fig. 91), 
two of these being employed, one placed inside the other during the 
process of drying, while one is covered with the other and held in 
position by a spring during the process of weighing. The weight of 
the glasses and clamp, as well as that of the filter, is deducted from 
the total weight, the difference indicating the weight of the uric 
acid in 200 c.c. of urine. As the uric acid, however, is slightly 
soluble in acidified urine and acidified water, a loss will always arise, 
if this method is employed. If but 30 c.c. of water are used during 
the process of washing, however, the loss will practically be counter- 
balanced by the weight of the coloring matter which is carried down 



THE CHEMISTRY OF THE URINE. 359 

by the crystals. It has been estimated, furthermore, that for every 
10 c.c. of water used, beyond the amount indicated, the addition of 
0.0045 gramme to the weight obtained will make up for the loss of 
uric acid resulting. 

While this method may be employed for clinical purposes, it must 
be remembered that at times only a portion of the uric acid, or none 
at all, separates out. Its absence, however, should not be inferred 
under such conditions, as its presence may be demonstrated by alka- 
linizing the acid filtrate and treating this with a solution of nitrate 
of silver, when a considerable precipitation may occur, which is re- 
ferable to the presence of uric acid. A test such as this should al- 
ways be made, and if a considerable cloudiness be obtained, recourse 
should be had to one of the more accurate methods described above. 
In addition to the precautions given the following should be noted : 
Urines rich in uric acid should be warmed after the addition of the 
hydrochloric acid until the cloudiness which occurs upon the addition 
of the reagent, owing to the presence of acid urates, has disappeared. 
If a sediment or cloudiness, due to urates, is noted in the urine, it 
should be warmed, and if necessary a small amount of alkali added, 
before the addition of the hydrochloric acid. 

The Xanthin Bases. 

The xanthin bases which have been found in the urine are xanthin, 
hypoxanthin, heteroxanthin, paraxanthin, guanin, and adenin. Con- 
jointly they are also spoken of as the alloxur bases, or purin bases. 
Together with uric acid they are termed alloxur or purin bodies. 
Their relation to uric acid and the nucleins has already been con- 
sidered (see p. 346). Unlike uric acid they also occur, as such, in 
animal as well as vegetable tissues. The amount, which appears in 
the urine under normal conditions, is very small, constituting about 
10 per cent, of the uric acid. Larger quantities may be met with 
in various diseases and generally speaking, an increase in the amount 
of uric acid is associated with an increase of the xanthin bases. 
This is, however, not invariably the case, and at times it may be 
observed that an increase of the uric acid is accompanied by a dimi- 
nution of the xanthins and vice iiersa. These varying relations can 
of course be readily understood, if we remember that uric acid is an 
oxidation product of the xanthin bases, and that their ultimate origin 
is the same. 

The literature which deals with the elimination of the xanthin 
bases in various diseases has during the past i'ew years assumed 
enormous proportions. This has largely been owing to the publica- 
tion by Kriiger and WulfFof a simple method for their quantitative 
estimation. Unfortunately, however, this method has proven un- 
reliable and the results which have thus been obtained, incorrect. 



360 THE URINE. 

Our knowledge of the relation of the xanthins to pathologic processes 
is hence as defective at the present time, as it was years ago. 

Individually the xanthin bases are as yet of little clinical interest. 
Xanthin has once been found in a urinary sediment, and has in 
several instances been encountered as the principal constituent of 
vesical calculi. Its normal quantity is said to vary between 0.02 
and 0.03 gramme. Larger quantities are found after a meal rich 
in nucleins, in leukaemia, nephritis, pneumonia, etc. 

Paraxanthin and heteroxanthin are present only in traces, as is ap- 
parent from the fact that Kriiger and Salomon were able to obtain 
but 7.5 grammes of heteroxanthin from 10,000 litres of urine. Both 
apparently are distinctly toxic. 

Xanthin sediments may be recognized by means of the following 
test : a small amount of the material is treated with a few drops of 
concentrated nitric acid, on a porcelain plate, and evaporated to dry- 
ness. In the presence of xanthin a yellow residue is obtained, which 
turns red upon the addition of a few drops of a sodium hydrate 
solution and the application of heat. The reaction is common to all 
the xanthins. 

Quantitative Estimation. — Salkowski's Method. — 600 c.c. of urine 
are precipitated with 200 c.c. of magnesia mixture (see p. 356), when 
a 3-per-cent. solution of nitrate of silver is added to from 700-750 
c.c. of the nitrate. The proportion should be 6 c.c. for every 100 
c.c. of urine. The silver nitrate solution should be added as described 
on p. 356. After standing for one hour, the mixture is filtered, and 
the precipitate washed with water, until all the free silver has been 
removed. The filter is then perforated, the precipitate washed into 
a flask with from 600-800 c.c. of water, acidified with hydrochloric 
acid, and decomposed with sulphuretted hydrogen. The excess of 
sulphuretted hydrogen is removed by heating on the water bath, 
when the sulphide of silver is filtered off, and the filtrate is evaporated 
to dryness. The residue is treated with from 25—30 c.c. of dilute 
sulphuric acid (1:100). This solution is brought to the boiling 
point and allowed to stand over night. The uric acid, which has 
then separated out is filtered oif, washed with a small amount of 
dilute sulphuric acid (not more than 50 c.c), then with alcohol and 
ether and weighed. To the resulting weight 0.0005 gramme is 
added for every 10 c.c. of the acid filtrate, to allow for the trace of 
uric acid which is thus lost. 

After having filtered off the uric acid, the filtrate is again treated 
with ammonia and silver solution, and the xanthin bases thus pre- 
cipitated. The precipitate is collected on a small filter, washed with 
water, dried and incinerated. The ash is dissolved in nitric acid, 
and the silver estimated by titration with a solution of potassium 
sulphocyanide, using ammonio-ferric alum as an indicator (see p. 



THE CHEMISTRY OF THE URINE. 361 

298). The solution of potassium sulphocyanide employed in the 
estimation of the chlorides may be used, and is of such strength that 
1 c.c. will correspond to 0.00734 gramme of silver. As one atom 
of silver in a mixture of the silver compounds of guanin, xanthin, 
hypoxanthin, etc., represents 0.277 gramme of nitrogen, or 0.7381 
gramme of the alloxur bases, it is apparent that 1 c.c. of the potas- 
sium sulphocyanide solution will represent 0.002 gramme of nitro- 
gen, and 0.00542 gramme of alloxur bases. In every case a care- 
ful account must of course be kept of the amount of urine and filtrate 
used. 

The amount of alloxur bases found by Salkowski in the normal 
urine of twenty-four hours varied between 0.0286 and 0.0561 
gramme. 

Hippuric Acid. 

Hippuric acid is a constant constituent of normal urine, 0.1 to 1 
gramme being excreted in the twenty-four hours. That it is derived, 
to some extent at least, from albuminous material is proved by the 
fact that its elimination is not suspended during starvation or during 
the administration of a purely albuminous diet. The manner in 
which hippuric acid is formed in the body-economy, however, has 
not been definitely ascertained. In vitro it may be obtained from 
glycocoll and benzoic acid, according to the equation : 

Benzoic acid. Glycocoll. Hippuric acid. 

C 6 H 5 + CH 2 NH 2 = CH 2 NH — C 6 H 5 CO + H 2 . 

Ill 
COOH COOH COOH 

It has been shown that phenyl-propionic acid, which differs from 
benzoic acid by the group C 2 H 4 , and which latter may be regarded 
as phenyl-formic acid, is produced during the process of intestinal 
putrefaction. The relation between the two bodies is seen from 
the formula? : 



Formic 


Phenyl-formic 


Propionic 


Phenyl-propionic 


acid. 


acid. 


acid. 


acid. 






CH 3 


CH^CfiHg 


H 


QHg 


1 


1 


1 m 


+ 1 


CH, a 


s->- CHj 


coon 


COOH 


1 


1 






COOH 


COOH 



Phenyl-propionic acid is then absorbed into the blood and there, 
according to our present ideas, transformed into phenyl-formic acid, 
or benzoic acid. When the latter comes in contact with glycocoll, 
which is probably also produced during the process of intestinal 
putrefaction, an interaction between the two substances occurs, hip- 
puric acid resulting, as shown in the above equation. This view is 



362 THE URINE. 

supported by the fact that phenyl-propionic acid, just as benzoic 
acid, when introduced into the circulation of certain animals, reap- 
pears in the urine as hippuric acid. The final proof of the possible 
synthesis of hippuric acid from glycocoll and benzoic acid in the 
body has been furnished by Bunge and Schmiedeberg, who obtained 
this substance, when arterialized blood containing glycocoll and 
sodium benzoate was allowed to pass through isolated kidneys of dogs. 

Not all the hippuric acid eliminated, however, is referable to 
albuminous material, but a considerable portion is derived from 
benzoic acid, or its derivatives, which latter are contained in many 
of our fruits, and are transformed into hippuric acid in the body. 
Among those which are particularly rich in these substances there 
must be mentioned the red bilberry, prunes, coffee-beans, reines- 
claudes, etc., and in all cases in which an increased elimination of 
hippuric acid is observed, the possibility of this source must always 
be taken into account. 

As to the seat of this synthesis there appears to be some uncer- 
tainty, as it is apparently not the same in all animals. In the dog 
and the frog the kidneys, according to the researches of Bunge and 
Schmiedeberg, must be regarded as the principal and possibly the 
only organs in which this process occurs. As Salomon, however, 
has demonstrated the presence of hippuric acid in the muscles, liver, 
and blood of nephrectomized rabbits, still other organs must, in the 
herbivora at least, be concerned in its production. 

Very little is known of the pathologic variations in the excretion 
of hippuric acid ; this is principally owing to the fact that until 
recently suitable methods for its quantitative estimation were un- 
known. It is an interesting fact that, in accordance with Bunge's 
experiments in dogs, the elimination of hippuric acid appears to be 
entirely suspended in cases of acute as well as chronic parenchyma- 
tous nephritis, for the benzoic acid, which is then ingested, reappears 
in the urine unchanged. In amyloid degeneration a marked dimi- 
nution in its amount has likewise been demonstrated. Large quan- 
tities of hippuric acid, on the other hand, have been noted in acute 
febrile diseases, hepatic diseases, diabetes mellitus, chorea, etc. The 
data, however, are insufficient to warrant any definite conclusions at 
the present time. 

Properties of Hippuric Acid. — Chemically, hippuric acid must 
be regarded as benzoyl-amido-acetic acid, C 9 H 9 N0 3 — (C 6 H 5 .CONH.- 
CH 2 COOH). It crystallizes in long rhombic prisms, when allowed 
to separate from its solutions gradually, while it forms long needles, 
if crystallization takes place rapidly and the amount is small (Fig. 
92). In water and ether it is soluble with difficulty, while it dis- 
solves readily in alcohol and in aqueous solutions of the hydrates 
and carbonates of the alkalies, forming salts, from which the acid 



THE CHEMISTRY OF THE URINE. 



363 



may again be separated and caused to crystallize out, by adding a 
stronger acid. 

When hippuric acid or one of its salts is evaporated to dryness 
with concentrated nitric acid and the residue heated, the odor of 
bitter almonds is noticed ; this is due to the formation of nitro-benzol. 

When boiled with hydrochloric acid or dilute sulphuric acid it is 
decomposed into glycocoll and benzoic acid. A similar decomposi- 
tion is effected daring the process of putrefaction, and hence no hip- 
puric acid is found in decomposing urine, benzoic acid taking its place. 
The latter is always found in the urine together with hippuric acid, 
but has no clinical significance. In large amounts it has recently 
been encountered in a case of diabetes. It crystallizes in needles or 
lustrous laminae, presenting ragged edges, which somewhat resemble 

Fig. 92. 




Hippuric-acid crystals. 



plates of cholesterin. It is soluble with difficulty in cold water, but 
easily soluble in ether, alcohol, and solutions of the alkaline car- 
bonates and hydrates, forming salts with the latter. 

Hippuric acid in the urine occurs in combination with sodium, 
potassium, calcium, and magnesium. 

Quantitative Estimation of Hippuric Acid. — The following- 
method, which may be employed for the quantitative estimation of 
hippuric acid, although very tedious, must also be employed when it 
is desired to test for its presence. 

Principle : Hippuric acid readily dissolves in solutions of the 
alkaline hydrates and carbonates, forming salts. These are decom- 
posed by means of a stronger acid, when the hippuric acid which 
separates out is collected and weighed. 

Method : Five hundred to one thousand e.c. of fresh urine are 
evaporated to a syrupy consistence on a water-bath, care being taken 



364 THE URINE. 

to keep the urine neutral by the addition of sodium carbonate. The 
residue is extracted with cold alcohol (90- to 95-per-cent.), taking 
about half of the quantity as that of the urine employed. The mix- 
ture is then set aside for twenty-four hours. The alcoholic filtrate, 
which contains the salts of hippuric acid, is freed from alcohol by 
distillation. The remaining solution is strongly acidified with acetic 
acid and extracted with at least five times its own volume of alcoholic 
ether (1 part of alcohol to 9 parts of ether). From the combined 
extracts the ether is distilled off and the remaining solution evap- 
orated on the water-bath. The resinous residue is boiled with water, 
set aside to cool, and filtered through a well-moistened filter. The 
hippuric acid, which is easily soluble in boiling water, is thus sepa- 
rated from other constituents which are soluble in alcohol and ether. 
The filtrate is rendered alkaline with a little milk of lime, any excess 
of calcium being removed by passing carbon dioxide through the mix- 
ture. This is then brought to the boiling-point and filtered. Any 
impurities which may be present are removed by shaking with ether. 
The calcium salts remaining in solution are decomposed by means of 
an acid and the solution again extracted with ether. The remaining 
solution is evaporated to a few c.c, when the hippuric acid will sepa- 
rate out on standing. The crystals are dried on plates of plaster- 
of-Paris, shaken with benzol or petroleum-ether to remove any ben- 
zoic acid, and finally weighed. These crystals may be shown to be 
hippuric acid by their microscopic appearance, their solubility in 
alcohol, and their behavior when evaporated with concentrated nitric 
acid, as indicated above. 

Hofmeister's Method. — Two hundred to three hundred c.c. of urine 
are evaporated in a glass dish to one-third of the original volume, 
treated with 4 grammes of disodium phosphate to transform the acid 
into its sodium salt. The mixture is evaporated to a syrupy con- 
sistence, the residue treated with burnt gypsum, dried thoroughly, 
and pulverized together with the dish. The powder is extracted in 
a Soxhlet apparatus with freshly rectified petroleum-ether (boiling- 
point 60° to 80° C.) for forty-six hours, and then for six to ten 
hours with pure ether (free from water and alcohol). After distilling 
off the ether, the residue is dissolved in boiling water and decolorized 
with animal charcoal, the latter being subsequently thoroughly 
washed with boiling water ; the solution and washings are evaporated 
to about 1 or 2 c.c. at a temperature of from 50° to 60° C, and set 
aside to crystallize. The crystals of hippuric acid are finally washed 
with a few drops of water and ether, and weighed. 

Kreatin and Kreatinin. 

Kreatin, which is constantly present in muscle tissue, is in all 
probability the immediate and constant antecedent of kreatinin, so 



THE CHEMISTRY OF THE URINE. 365 

that two sources of this body must be recognized, viz, the muscle- 
tissue of the body and the muscle-tissue ingested as food. Beyond 
this, however, practically nothing is known, and as the artificial pro- 
duction of kreatinin from albuminous material has so far never been 
accomplished, it is hardly warrantable to venture an hypothesis as 
to its mode of formation in the body. 

Kreatinin is a constant constituent of the urine, about 1 gramme 
being daily excreted by a healthy adult. Pathologically variations in 
this amount have been observed, but the data so far obtained possess 
little value. Before drawing conclusions from any observations, 
which are made in the clinical laboratory, it is necessary to take into 
account the quantity of meat ingested, as a meat-diet will greatly 
increase the amount of kreatinin. If then in patients affected with 
acute febrile diseases, such as pneumonia, typhoid fever, etc., a large 
increase is observed, the patient being at the same time upon a milk- 
diet, an increased destruction of muscle-tissue may be inferred, as a 
milk-diet in itself, ceteris paribus, causes a diminished elimination. A 
decrease would logically be expected to occur during convalescence 
from such diseases. In the various forms of anaemia, marasmus, 
chlorosis, phthisis, etc., a diminished amount is observed. 

The transformation of kreatin into kreatinin has been supposed to 
take place in the kidneys, a view which accords with the greatly 
diminished excretion of kreatinin in well-advanced cases of chronic 
parenchymatous nephritis. In progressive muscular atrophy, in 
pseudo-hypertrophic paralysis, and in progressive ossifying myositis 
a diminution has also been noted. 

Properties of Kreatin and Kreatinin. — Chemically kreatin may 
be regarded as a methyl derivative of glycocyanin, which latter is 
guanidin in which one NH 2 group has been replaced by glycocoll. 
Kreatinin, on the other hand, is the methyl derivative of glycocy- 
anidin, which differs from glycocyanin only in the absence of 1 
molecule of water, so that kreatinin is kreatin minus 1 molecule of 
water, both being derivatives of guanidin. The relation between 
the various bodies is shown below ; 

Guanidin. 

/NH 2 
C=NH 

\NH 2 

Glycocyanin. Kreatin. 

/NH 2 /NH„ 

C=NH C=NH 

\NH.CH 2 . COOH \N( CH 3 ) . CIL. COOH 

(ilycocyanidin (glycocyanin minus water). Kreatinin (kreatin minus water). 

/Nil /Nil 

C=NII C=N 

\NII.CIT.,.CO \N(CH s ).CH 8 .CO 



366 



THE URINE. 



Kreatinin crystallizes without water of crystallization in colorless, 
glistening prisms. At times, when the crystals are not w T ell devel- 
oped, it also appears in the form of whetstones. It is readily soluble 
in hot and also quite soluble in cold water and hot alcohol ; in cold 
alcohol and ether it dissolves with difficulty. 

It forms salts with acids, and double salts with some of the salts 
of the heavy metals. Among these may be mentioned kreatinin 
hydrochloride, C 4 H 7 N 3 0.HC1, which is easily soluble in water and 
crystallizes in the form of transparent prisms or rhombic plates. 
Most important is the compound of kreatinin with zinc chloride, 
(C 4 H 7 N 3 0) 2 .ZnCl 2 (Fig. 93). This is produced when a watery or 
alcoholic solution of kreatinin is treated with chloride of zinc. The 
crystalline form of this compound depends greatly upon the purity 

Fig. 93. 




Crystals of kreatinin-zinc chloride. (Salkowski. ) 



of the kreatinin solution. When obtained from alcoholic extracts 
of the urine, it occurs in the form of varicose conglomerations which 
often adhere firmly to the walls of the vessel. If the solution of 
kreatinin is perfectly pure, however, it is seen in the form of fine 
needles grouped together in rosettes or sheaves. Kreatinin-zinc 
chloride is soluble with much difficulty in water and insoluble in 
alcohol. This compound is especially important, as upon its forma- 
tion and properties the quantitative estimation of kreatinin in the 
urine is based. Nitrate of silver and mercuric chloride cause a pre- 
cipitation of kreatinin, and may, therefore, also be employed for the 
purpose of obtaining the substance from the urine. 

Test for Kreatinin in the Urine. — A few c.c. of urine are treated 
with a few drops of a very dilute solution of sodium nitro-prusside, 
and then drop by drop with a dilute solution of sodium hydrate ; 



THE CHEMISTRY OF THE URINE. 367 

in the presence of kreatinin the urine assumes a ruby-red color, 
which is particularly well seen in the lower portion of the tube. 
This color disappears after a few minutes, and is replaced by an in- 
tense yellow, which, on warming with glacial acetic acid in pure so- 
lutions, turns to green ( WeyVs test). The presence of albumin or 
sugar does not interfere with the reaction. 

Quantitative Estimation of Kreatinin in the Urine. — Principle : 
When an alcoholic extract of the urine is treated with an alcoholic 
solution of zinc chloride, kreatinin-zinc chloride separates out. 
This, as has been mentioned, is almost insoluble in alcohol. Know- 
ing the molecular weight of kreatinin and kreatinin-zinc chloride, 
the calculation of the amount of kreatinin becomes a simple matter. 
The molecular Aveight of kreatinin is 113, that of kreatinin-zinc 
chloride 362. In 362 parts by weight of the latter there are, hence, 
226 parts by weight of kreatinin, so that the amount of the kreatinin 
may be calculated from the weight of the kreatinin-zinc chloride ac- 
cording to the following equation : 362 : 226 :: y : x, and x = 
0.6243y, in which y indicates the weight of the kreatinin-zinc 
chloride found, and x the corresponding amount of kreatinin. The 
phosphates must, of course, first be eliminated, as insoluble zinc 
phosphate would otherwise be precipitated. 

Method : — In 240 c.c. of urine the phosphates are first removed 
by rendering the urine alkaline with milk of lime, and then adding 
calcium chloride so long as a precipitate forms. If the volume is 
now less than 300 c.c, water is added to that amount. The mixture 
is filtered after having been allowed to stand for one-quarter to one- 
half hour, and washed with a little water ; 250 c.c. of the mixture 
are then measured off, and slightly acidified with dilute hydrochloric 
acid, so as to prevent the transformation of kreatinin into kreatin 
during the long process of evaporation. This amount is evaporated 
on the water-bath to a syrupy consistence, and then thoroughly mixed 
with 20 to 30 c.c. of absolute alcohol. The mixture is poured into 
a stoppered flask provided with a 100 c.c. mark, and after thor- 
oughly rinsing out the evaporating-dish with absolute alcohol the 
washings are also placed in the bottle, and absolute alcohol added to 
the mark. The bottle is thoroughly shaken and set aside in a cool 
place for twenty-four hours, the mixture being agitated from time to 
time. It is now filtered and rendered slightly alkaline with a drop 
or two of a sodium carbonate solution, as kreatinin hydrochloride is 
not precipitated by chloride of zinc. The reaction, however, should 
be only faintly alkaline, as otherwise zinc oxide will be precipitated. 
The mixture is now slightly acidified with acetic acid. Eighty c.c. 
corresponding to 160 c.c. of urine, are treated with 10. to 15 drops 
of an alcoholic solution of zinc chloride, prepared by dissolving the 
salt in 80-per-eent. alcohol and diluting with 95-per-cent. alcohol to 



368 THE URINE. 

a specific gravity of 1.2. The mixture is then veil stirred and set 
aside in a cool place for two or three days. The crystals, which are 
usually deposited on the sides of the vessel in the form of wart- like 
masses, are then collected upon a dried and weighed filter, always 
using portions of the filtrate to bring the crystals completely upon 
the filter. These are washed with a small amount of 90-per-cent. 
alcohol, until the washings are without color and give only a slight 
opalescence when treated with a drop of nitrate of silver solution. 
The crystals are finally dried at a temperature of 100°C., and 
weighed. By multiplying the weight thus found by 0.6243 the 
amount of kreatinin is obtained. 

Precautions. — 1. Albumin and sugar, if present, must first be 
removed. In diabetic urines it is best, after having removed the 
sugar by fermentation, to take one-fifth of the total quantity elimi- 
nated in twenty-four hours, and to evaporate this to about 300 c.c, 
before removing the phosphates. 

2. The weighed material should be examined microscopically to see 
whether notable quantities of sodium chloride are present. Should 
such be the case it is necessary to determine the amount of zinc present, 
and to estimate the kreatinin from this. To this end the alcoholic 
solution containing the kreatinin-zinc chloride is evaporated to dry- 
ness after the addition of a little nitric acid. The residue is incin- 
erated, extracted with water, washed, dried, fused, and finally 
weighed. 

As 100 parts of kreatinin-zinc chloride correspond to 22.4 parts 
by weight of zinc oxide, the corresponding amount of the compound 
is found according to the following equation : 22.4 : 100 : : y : x, 
and x = 4.4642, in which y represents the amount of zinc oxide 
found, and x the corresponding amount of kreatinin-zinc chloride. 
By multiplying the number thus ascertained by 0.6243 the amount 
of kreatinin is found. 

3. Instead of doing this the precipitate in the alcoholic solution 
may be examined microscopically before filtering. If sodium chlo- 
ride crystals are found, providing that the kreatinin-zinc chloride 
adheres to the sides of the vessel, the sodium chloride may be dis- 
solved in a little water and poured off. 

4. If the crystals of kreatinin-zinc chloride adhere very firmly 
to the sides of the vessel, so that their removal would be in- 
complete, it is perhaps best to dissolve them in a little hot 
water, to evaporate to dryness, and to weigh the kreatinin compound 
directly. 

5. If the urine shows an alkaline reaction, it is best to acidify 
with sulphuric acid, and to boil for half an hour before removing the 
phosphates, so as to transform any kreatin that may be present into 
kreatinin, when the examination is continued as described. 



THE CHEMISTRY OF THE URINE. 369 

Oxalic Acid. 

The origin of oxalic acid in normal urine appears to be twofold, 
one portion being referable to vegetable food ingested, while the 
other originates in the body, in a manner not definitely understood at 
the present time. It is quite probable, however, that this latter 
portion is derived, to some extent at least, from uric acid through 
a process of oxidation. This view is supported by the artificial 
production of oxaluric acid from uric acid, the former being like- 
wise a constant constituent of the urine. Oxaluric acid is readily 
decomposed into oxalic acid and urea, as is seen from the following 
equations : 

Uric acid. Alloxan. Urea. 

1 . C 5 H,N 4 3 + O + H 2 = C 4 H 2 N 2 4 + CON T 2 H 4 . 

Alloxan. Parabanic acid. 

•NH.CO 

2. C 4 H 2 N 2 4 + = CC\ I +C0 2 . 



\nh. 



CO 



Parabanic acid. Oxaluric acid. 

/NH. CO CO— NH— CONH 2 

3. CO< I +H 2 0=| 

\NH.CO CO. OH 

Oxaluric acid. Oxalic acid. Urea. 

CO— NH— CONH 2 CO— OH /NH 2 

4. | + H s O=| +CO< i- 
CO.OH CO— OH \NH 2 

Oxalic acid may also result from an incomplete oxidation of car- 
bohydrates. 

From a pathologic standpoint the study of the excretion of oxalic 
acid is of decided importance. Care should, however, be taken in 
the interpretation of the results reached by a chemical examination, 
as many vegetables are capable of producing an excessive excretion 
of this acid. Among these may be mentioned tomatoes, spinach, 
carrots, celery, string-beans, asparagus, apples, grapes, etc. 

Gastro-intestinal disturbances are very apt to cause an increased 
elimination of oxalic acid, probably in consequence of a defective 
digestion and subsequent oxidation of carbohydrates, the so-called 
nervous oxaluria being probably of this origin. Very interesting 
is the form of oxaluria observed in eases of transient albuminuria, 
described by Senator and confirmed by v. Noorden and others. To 
this class the so-called Albuminuria and Brighfs Disease qf Uric 
Acid and of Oxalic Acid of Da Costa in all probability also belongs. 

In the chapter on Phosphates it was shown that in diabetes mel- 
litus a certain relation appears to exist, at times, between the excretion 
of sugar and phosphates, as these bodies increase and decrease in 
24 



370 THE URINE. 

an inverse relation to each other. A similar condition is also noted 
in the excretion of uric acid. In the case of oxalic acid such a 
vicarious elimination, as it were, is likewise not infrequently ob- 
served, and may at times be very pronounced, indicating the exist- 
ence of a probable relation between carbohydrates and oxalic acid. 

The oxalic acid diathesis, or idiopathic oxaluria, must finally be 
considered. In this condition there is associated with a definitely 
recognizable increased production a temporary retention, followed 
by an increased elimination of oxalic acid, notwithstanding the fact 
that a .perfectly normal diet — i. e., one not especially rich in oxalic 
acid-containing constituents — is taken. There can thus be no doubt 
of the occurrence of abnormal metabolic processes in the body. 
These are probably similar to those giving rise to diabetes mellitus, 
in AAiiich a suspended oxidation apparently occurs, while an insufficient 
oxidation is observed in idiopathic oxaluria. The relation between 
the two diseases is further shown by the vicarious elimination of 
oxalic acid in diabetes. 

Properties of Oxalic Acid. — Oxalic acid occurs in the urine as 
calcium oxalate, CaC 2 4 , and is held in solution by the diacid sodium 

Fig. 94. 




Calcium oxalate crystals. 

phosphate. It can, hence, be precipitated by diminishing the acidity 
of the urine by the addition of a little ammonia, or by allowing it 
to stand exposed to the air. Calcium oxalate, when allowed to crys- 
tallize out slowly, occurs in the form of well-defined, strongly re- 
fractive octahedra, the well-known envelope forms resulting, in 
which the principal axis of the crystals is placed at right angles to 
the plane of the microscope slide (Fig. 94). 

Calcium oxalate is readily recognized by its characteristic crystals, 
its insolubility in acetic acid, and its solubility in hydrochloric acid. 
When strongly heated it is decomposed into calcium oxide, carbon 
dioxide, and carbon monoxide, according to the equation : 

CaCA = CaO + CO, + CO. 



THE CHEMISTRY OF THE URINE. 371 

The quantity excreted in the twenty-four hours varies from faint 
traces to 20 milligrammes. It should be remembered that an in- 
creased or diminished excretion of oxalic acid cannot be determined by 
a microscopic examination of the sediment, as numerous crystals of 
oxalate of calcium may be seen, when a quantitative estimation actually 
shows a diminution of the normal amount, and. vice versa. 

Tests for Oxalic Acid. — For the detection of calcium oxalate it 
is frequently only necessary to examine the sediment of the urine, 
after twenty-four to forty-eight hours. But, as I have just pointed 
out, no oxalate crystals may be found, even when an abnormally 
large amount can be demonstrated by chemical methods. In such 
cases it is usually possible to bring about the crystallization of the 
salt by carefully neutralizing the urine with a little ammonia. Should 
this procedure not lead to the desired end, it is best to proceed by a 
method, which may at the same time be employed for its quantitative 
estimation. 

Quantitative Estimation of Oxalic Acid. — Principle : The 
oxalate of calcium in the urine is held in solution by the diacid 
sodium phosphate. If this is removed by means of calcium chloride 
and ammonia, the calcium oxalate is precipitated. By heating this 
strongly it is transformed into calcium oxide. 

As 56 parts by weight of calcium oxide correspond to 128 parts 
by weight of calcium oxalate, the amount of the latter can be 
readily calculated according to the equation :56:128::y:x, and 
x = 2.2857y, in which y indicates the amount of calcium oxide 
found in a given amount of urine, and x the corresponding amount 
of calcium oxalate. As 1 molecule of oxalic acid, moreover, corre- 
sponds to 1 molecule of calcium oxalate, the amount of the former 
can be found from that of the latter according to the equation : 
128 : 90 :: y : x, and x = 0.703y, in which y represents the amount ol 
calcium oxalate found, and x the amount of the corresponding acid. 

Method. — A large amount of urine (600 to 1,000 c.c), after 
having been treated with a small amount of an alcoholic solution of 
thymol, so as to guard against putrefactive processes, is treated with 
calcium chloride and ammonia, added in excess. The diacid sodium 
phosphate which holds the oxalic acid in solution is thus removed. 
The precipitate of phosphates is then carefully treated with an 
amount of acetic acid just sufficient to dissolve it. As calcium 
oxalate is insoluble in acetic acid, it gradually separates out. To 
this end the mixture is allowed to stand for twenty-four hours, the 
addition of the thymol preventing the development of bacteria. At 
the end of this time the calcium oxalate is filtered off through a 
small filter. It is then washed with a small amount of water and 
dissolved with a few drops of hydrochloric acid, any uric acid that 
may have separated out being left behind. The filtrate is further 



372 THE URINE. 

treated with a small amount of very dilute ammonia, so as to render 
the solution slightly alkaline. After standing for twenty-four hours 
the calcium oxalate will have separated out, and is collected upon a 
small filter, the weight of the ash in this being known. After wash- 
ing with water the contents of the filter are dried and incinerated in 
a crucible, heating strongly for about twenty minutes, whereby the 
oxalate is transformed into the oxide. From the weight of this the 
corresponding amount of oxalic acid is readily calculated according 
to directions given above. 

Albumins. 

The albumins which may be met with in the urine are : Serum- 
albumin, serum-globulin, albumoses (peptones), haemoglobin, nucleo- 
albumin, fibrin, and histon. Of these, serum-albumin is the most 
important from a clinical standpoint. 

Serum- albumin. — The question whether or not serum-albumin 
occurs normally in the urine — i. e., under strictly physiologic con- 
ditions — has been much disputed. It is claimed by some that traces 
may be temporarily met with in apparently healthy individuals after 
severe muscular exercise, cold baths, mental labor, severe emotions, 
during menstruation, digestion, etc. This so-called physiologic albu- 
minuria mostly occurs in young adults, and is usually, if not always, 
of brief duration. The urine, it is claimed, is otherwise normal — 
i. e., of normal amount, appearance, specific gravity, and composi- 
tion, and free from abnormal morphologic constituents, such as casts, 
red corpuscles, leucocytes, and epithelial cells. 

The existence of a physiologic albuminuria, on the other hand, is 
denied, and the occurrence of serum-albumin at least regarded as 
pathologic in every case. I have never been able to convince myself 
of the occurrence of serum-albumin in the urine under strictly physio- 
logic conditions, and it has already been pointed out elsewhere that 
severe muscular and mental labor, severe mental emotions, cold 
baths, etc., can hardly be regarded as physiologic stimuli for all per- 
sons. The albuminuria, so often observed during the first days of 
life, at which time sediments of uric acid and urates, mucus, epithe- 
lial cells from the different portions of the urinary tract, and even 
casts may also be seen, i. e., constituents which in adults would 
rightly be regarded as abnormal, has also been brought forward in 
support of the theory of a physiologic albuminuria. There can be 
no doubt, however, that this form of albuminuria is referable to the 
profound changes that take place in the circulatory system after 
birth, and to some extent perhaps also to the well-known uric-acid 
infarctions, so frequently seen in the kidneys of the newly born, so 
that it would probably be better and more in accord with the teach- 
ings of pathology to regard this form of albuminuria also as abnormal. 



THE CHEMISTRY OF THE URINE. 373 

The more closely the subject of the so-called physiologic albu- 
minuria is studied the more improbable does its physiologic nature 
appear, and a more detailed study of the metabolic processes, it may 
be confidently asserted, will ultimately lead to the conclusion that 
the presence of albumin in every case is a pathologic phenomenon. 

The association of an increased elimination of urea and uric acid 
with albuminuria in apparently healthy individuals was noted twenty- 
five years ago, but received comparatively little attention. More 
recently, Da Costa, in a paper entitled u The Albuminuria and 
Bright' s Disease of Uric Acid and Oxalic Acid," pointed out the 
existence of albuminuria associated with lithuria and oxaluria. Per- 
sonal observations have led me to look upon this form of albuminuria 
as of common occurrence, and while in almost every case the albumin 
can be caused to disappear from the urine by proper diet and exer- 
cise, there can be no doubt that, if neglected, granular atrophy may 
ultimately result. 

An albuminuria may at times be observed in anaemic children 
and adolescents, and particularly in masturbating boys of the mouth- 
breathing type, but can hardly be regarded as physiologic. The 
same may be said of the albuminuria of pregnancy and parturition. 

The course which may be taken by these various forms of what 
should be termed functional albuminuria, in which the amount of 
albumin rarely exceeds 0.1 per cent., is very interesting. The elimi- 
nation of albumin may thus be quite transitory on the one hand, as 
when following severe muscular exercise, cold baths, and the like. 
It may, however, also last for several days or even weeks, and be fol- 
lowed by a disappearance of the albumin for a variable length of 
time, and again by its reappearance and continuance for days and 
weeks. The term intermittent albuminuria has been applied to this 
latter type. At times the albuminuria may follow a definite course, 
disappearing and reappearing with such regularity that it has not 
improperly been styled cyclic albuminuria. In this form the albumin 
generally disappears from the urine during the night, or during a 
prolonged rest in bed, and reappears during the day, the erect pos- 
ture apparently favoring its reappearance ; the term postural albu- 
minuria has hence also been suggested for this form. Osswald, who 
made a careful study of cyclic albuminuria in RiegeFs clinic, regards 
its occurrence as distinctly pathologic, and as indicating the existence 
of nephritis. Remembering the importance of the subject, it may 
not be out of place to enumerate the reasons which led Osswald to 
this conclusion : 

1. The patients generally come to the physician complaining of 
certain definite symptoms, which are the same as those noted in eases 
of true nephritis. At times, however, no complaints are made, be- 
cause the patients have reasons for concealing them (as in examina- 



374 THE URINE. 

tions for life-insurance), or because they are for the time being 
absent. 

2. The subjective complaints, as well as the anaemia so frequently 
observed in such cases, generally disappear, together with the albu- 
min, under suitable treatment, and reappear when the ansemia again 
becomes marked. 

3. In many a history of an antecedent nephritis, the result of 
scarlatina or diphtheria, may be obtained, as in three cases of Heub- 
ner, in fourteen cases out of twenty described by Johnson, etc. In 
some also a direct transition from an acute nephritis to the cyclic 
form of albuminuria has been noted. Where this was not possible 
the history of an acute infectious disease or an angina, that had been 
overlooked in the clinical history, must be regarded as a possible 
cause. 

4. The absence of morphologic elements, especially tube-casts, 
does not exclude a nephritis. A large number of cases, moreover, 
have recently been observed in which casts were repeatedly found. 

5. A cyclic albuminuria may be observed in many cases of chronic 
nephritis. 

6. Marked organic abnormal ties (such as heart-lesions) need not 
be demonstrable, as they may be absent for a long period of time, or 
may be unrecognizable. 

Senator's statement, that the existence of a physiologic albuminuria 
is proved by the fact that the morphologic constituents of the prim- 
itive nubecula contain albumin, requires no further criticism, and 
should be regarded as a misconstruction of the main point at issue — 
a mere sophism — and Posner's observations, in view of the researches 
of Malfatti, which tend to show that the body obtained by Posner 
was not serum-albumin, but a nucleo-albumin, may now be regarded 
as erroneous. 

In conclusion, it may be safely asserted that a transitory, intermittent, 
and cyclic albuminuria is not infrequently observed in apparently 
healthy individuals, but that the facts so far brought forward do not 
warrant the assumption that such forms of albuminuria are physiologic. 

It would lead too far to enter into a detailed consideration of the 
various causes that have from time to time been suggested as an ex- 
planation of the fact that albumin does not occur in the urine under 
normal conditions. There can be no doubt, however, that the integ- 
rity of the epithelial lining of the glomeruli and the convoluted 
tubules must be regarded as the principal factor which prevents the 
albumin of the blood from passing into the urine. When the read- 
iness with which the glandular structure of the kidney responds to 
any abnormal stimulation is considered, it is easily understood how 
an albuminuria may be produced in many different ways. Aside 
from acute and chronic inflammatory processes in the widest sense 



THE CHEMISTRY OF THE URINE. 375 

of the word, an albuminuria may be the result of circulatory dis- 
turbances in the kidneys of whatever kind — i. e., the result of an- 
aemia, as well as of hyperemia. In many and perhaps the majority 
of cases, in which, what Bamberger terms a hcematogenous albumi- 
nuria, occurs, we have direct evidence of the existence of circu- 
latory disturbances, as in cases of uncompensated valvular lesions, 
weak heart, emphysema, hepatic cirrhosis, etc. In other cases, 
however, the existence of such disturbances can only be surmised, 
and the question, whether or not the albuminuria, observed in the 
various infectious diseases, for example, is referable to circulatory ab- 
normalities, or to a direct irritative action of microbic poisons upon 
the renal parenchyma, must still remain an open one. 

From personal studies in connection with the [functional albu- 
minuria of Da Costa, it seems not unlikely that in many cases in 
which obscure circulatory disturbances are supposed to exist and 
made responsible for an existing albuminuria, this is referable rather 
to the strain thrown upon the kidneys by the continued elimination 
of abnormally large quantities of organic material, the quantity of 
water being at the same time proportionately small. 

If it is remembered, furthermore, that injuries affecting certain 
portions of the brain are followed by albuminuria, and that this 
may be artificially produced by a piqure, analogous to the glycosuric 
piqure of C. Bernard, still another factor is given which may pos- 
sibly enter into the causation of albuminuria. 

Obstruction to the outflow of urine from the kidneys has also 
been experimentally shown to lead to albuminuria, an observation 
with which clinical experience is in perfect accord. 

Finally, an abnormal composition of the blood may at times cause 
the albuminuria. 

In passing on to a more detailed study of the various pathologic 
conditions in which an elimination of albumin may be noted, an 
attempt will be made to classify the various forms of albuminuria 
in accordance with the more general considerations set forth above. 
It should be remembered, however, as already indicated, that it may 
be very difficult, if not impossible, to assign one single cause to a 
given clinical case, as several factors may at the same time be con- 
cerned in the production of the albuminuria. 

1. Functional Albuminuria. — Under this heading may be 
comprised the various forms of " physiologic " albuminuria, which 
have already been considered. 

2. The Albuminuria Associated with Organic Diseases 
of the Kidneys ; viz, acute and chronic nephritis, renal arterio- 
sclerosis, amyloid degeneration of the kidneys. 

In acute nephritis, albuminuria, usually of great intensity, is a 
constant and most important symptom. The amount eliminated 



376 THE URINE. 

is generally proportionate to the intensity of the disease, but varies 
within fairly wide limits, generally from 0.3 to 1 per cent., corre- 
sponding to a daily excretion of from 5 to 8 grammes. Much larger 
quantities, it is true, are at times excreted, but it may be definitely 
stated that the daily loss of albumin seldom exceeds 20 grammes. 

In chronic parenchymatous nephritis the elimination of albumin is 
likewise constant, and the amount excreted in severe cases may even ex- 
ceed that observed in the acute form. An elimination of from 15 to 30 
grammes, viz, 1.5 to 3 per cent, by weight, is frequently observed. 

In the ordinary form of chronic interstitial nephritis the elimina- 
tion of albumin is, as a general rule, slight, and rarely amounts to 
more than 2 to 5 grammes pro die. At the same time it is not 
unusual to meet with an apparent absence of albumin, if the more 
common tests (see below) are employed. If it is remembered that 
very often the diagnosis of the disease is dependent upon the dem- 
onstration of the presence or absence of albumin, the necessity of 
frequent examinations and the employment of more delicate tests, 
particularly of the trichloracetic-acid test, as well as of a microscopic 
examination, is at once apparent. This is even of greater importance 
in the renal arterio-sclerosis of Senator, in which albumin by the 
ordinary tests is probably not demonstrable in the majority of cases, 
and in which even the trichloracetic-acid test may not be of service, 
and casts are absent. 

Amyloid degeneration of the kidneys, in the absence of inflamma- 
tory processes, is accompanied by a condition of the urine, closely 
resembling that observed in the ordinary form of chronic interstitial 
nephritis. A total absence of albumin, however, is less frequently 
noted, while an amount varying between 1 and 2 per cent, is not 
at all uncommon. It will be shown later on that in this condition 
considerable amounts of serum-globulin are excreted in addition to 
the serum-albumin ; larger amounts, in fact, than are generally ob- 
served in this form of chronic renal disease, so that Senator sug- 
gests that such a relation, in the absence of an acute nephritis, or an 
acute exacerbation of a chronic nephritis, may be of a certain diag- 
nostic value. 

3. Febrile albuminuria. — That albuminuria may occur in almost 
any one of the various febrile diseases is a well-known fact, but it 
is important to remember that, while such an albuminuria may at 
times be referable to a true nephritis developing in the course of 
or during convalescence from an acute febrile disease, such is the 
exception, and not the rule. Under this heading only that form 
will be considered which is not associated with distinct changes 
affecting the renal parenchyma, and which generally appears during 
the height of the disease only, to disappear again with a return of 
the temperature to normal limits. As has already been mentioned, 



THE CHEMISTRY OF THE URINE. 377 

it is often very difficult, if not impossible, to assign a definite cause 
for the occurrence of an albuminuria of this character, and in all 
probability several factors are in operation at the same time. In the 
beginning of the disease, when the blood-pressure, as a rule, is in- 
creased, the albuminuria may be referable to an ischsemia of the 
kidneys, as the increased pressure in fever, according to Cohnheim 
and Mendelson, is largely referable to spasm of the arterioles. 
Later on, or in the beginning of cases in which especially severe 
intoxication exists, the blood-pressure may be subnormal, and the 
albuminuria be due to this cause — L e., a hypersemic condition of 
the kidneys. As a matter of fact, it has been experimentally demon- 
strated that both anaemia and hyperemia of the kidney structure 
may lead to albuminuria. On the other hand, it is not at all un- 
likely that the strain thrown upon the kidneys by an excessive 
elimination of organic material, in the absence of a correspondingly 
large quantity of water, may produce albuminuria. I have repeat- 
edly seen the functional albuminuria of the type described by Da 
Costa disappear during the administration of a diet relatively poor 
in nitrogen, while an increased diuresis was at the same time effected 
by the consumption of large amounts of water. 

In those grave cases of typhoid fever, furthermore, which are 
characterized by high fever and pronounced nervous symptoms it 
would appear quite likely that the albuminuria, which in these cases 
is particularly marked, is referable to a direct influence upon the 
central nervous system, and in some cases, at least, also dependent 
upon an irritant action on the part of the microbic poisons circulating 
in the blood upon the renal epithelium. The character of the albu- 
minuria will largely depend upon the intensity of the intoxication ; 
in other words, upon the amount of bacterial poison present at any 
one time in the blood. 

Notwithstanding the statements to the contrary, albuminuria may 
be regarded as a constant symptom of typhoid fever, as has been 
definitely demonstrated by Gubler and Robin. It is difficult to say 
why other observers have found albumin in only a comparatively small 
percentage of cases, but it is not unlikely that this is owing to a lack 
of uniformity in methods, it being presupposed also that questions 
of this kind can only be decided by daily examinations. According 
to Robin, the trace of albumin which is at times observed during 
the first week of the disease is an albumose, while later on serum- 
albumin is constantly found ; the amount increases with the inten- 
sity of the morbid process, and the highest figures arc reached in fatal 
cases. The more severe the disease the earlier does albumin appear 
in the urine, it being remembered, however, that reference is had 
only to those cases in which distinct renal changes arc not demon- 
strable. Toward the termination of the fasti giurn the amount of 



378 THE URINE. 

albumin generally undergoes a certain diminution, and may even 
disappear entirely. This diminution, however, is only temporary, 
and in severe cases the albumin again increases in amount during 
the period of the great variations in the temperature. In light cases 
an increased elimination also takes place at this stage, but is soon 
followed by a decrease, after which only traces can be demonstrated. 
In some also, it disappears entirely, but it is rare, according to Robin, 
to meet with cases in which a trace at least does not reappear during 
convalescence. 

In light cases the albuminuria rarely persists longer than the fifth 
or eighth day of convalescence, and Robin even goes so far as to say 
that a relapse may be anticipated, if the albuminuria does not disap- 
pear at that time. A limited number of personal observations have 
borne out the correctness of this view, and in one case, in which a 
relapse occurred so late as the fifteenth day of convalescence, traces 
of albumin could be demonstrated during the entire period. In 
severe cases, on the other hand, the albumin persists for a variable 
length of time, and rarely disappears before the tenth day of con- 
valescence. At times an increase is seen during convalescence, when 
traces only have previously been observed. It is this form which 
the French generally speak of as colliquative albuminuria. While 
this form is principally observed in typhoid fever, it is not unusual 
to meet with it during the convalescence from various other acute 
diseases. Care must be taken not to confound the albuminuria so 
frequently seen during the convalescence from typhoid fever, refer- 
able to a pyelitis, with the form just described. 

From the following table, constructed from data given in Robin's 
most excellent work on the urine of typhoid fever and other acute 
infectious diseases, which may be associated with a typhoid condition, 
an idea may be formed of the occurrence of albuminuria, as well as 
of its degree of intensity in these diseases : 

Acute miliary tuberculosis : Albumin much less frequent than in 
typhoid fever ; when present it is rarely found in the abundance so 
characteristic of the fatal cases of the latter disease. 

Pneumonia : Albumin is as uniformly present as in typhoid fever, 
and at times very abundant. 

Grippe : Albumin infrequent ; present in about 20 per cent, of 
the cases, and only in traces. 

Herpetic fever : Albumin never present in large amounts. 

Embarras gastrique : Albumin rarely present. 

Adynamic enteritis of adults : Albumin almost always present, but 
usually only in traces. 

Cerebro-spinal meningitis : Albumin in fairly large amounts. 

Vegetative endocarditis : Albumin very abundant in about 14 per 
cent., evident in 44 per cent., and traces in 42 per cent. 



THE CHEMISTRY OF THE URINE. 379 

Acute articular rheumatism : Albumin present in about 40 per 
cent. 

Rubeola : Albumin usually absent in light cases, but present in 
the more severe and complicated forms. 

Intermittent fever : Albumin variable. 

In conclusion, it may be said that practically every acute febrile 
disease, even simple follicular tonsillitis, may be accompanied by 
albuminuria, in the absence of definite changes affecting the renal 
parenchyma. Its occurrence in an individual case is probably de- 
pendent, to a very large degree, upon the intensity of the intoxica- 
tion. "While it is generally an easy matter to distinguish between 
this form of albuminuria and that associated with distinct organic 
changes in the kidneys, considerable difficulty may at times be ex- 
perienced ; this question will be dealt with later on. 

4. Albuminuria Referable to Circulatory Disturbances. 
— To this class belongs the albuminuria so frequently observed in 
cardiac insufficiency referable to valvular lesions, degeneration of the 
heart-muscle from whatever cause, disease of the coronary arteries, 
etc., as well as in cases of impeded pulmonary circulation affecting 
the general circulation through the right heart, and, finally, in con- 
ditions associated with local circulatory disturbances, such as com- 
pression of the renal veins by a pregnant uterus, tumors, etc. It 
has already been pointed out that febrile albuminuria also may, to a 
certain extent, at least, be referable to such causes ; i. e., an ischaemia 
or hyperemia of the kidneys, produced by an increased or diminished 
blood-pressure. The albuminuria observed in cases of cholera in- 
fantum, the simpler forms of intestinal catarrh, and in cholera 
Asiatica particularly, are undoubtedly dependent upon such causes. 
The occurrence of albuminuria after cold baths, as stated above, is 
regarded by many as a " physiologic " phenomenon, but this view 
should be rejected, as there can be but little doubt that this form is 
also referable to circulatory disturbances. The quantity of albumin 
found under these circumstances varies considerably, but rarely ex- 
ceeds 0.1-0.2 per cent., unless the disease has advanced to a point, 
where distinct changes in the renal parenchyma have resulted. 

5. Albuminuria Referable to an Impeded Outflow of 
Urine. — Clinically, albuminuria referable primarily to an impeded 
outflow of urine from the kidneys is probably of more frequent oc- 
currence, than is generally supposed, and especially in women, in whom 
Kelly and others have demonstrated the frequent existence of ureteral 
stenoses. A complete blocking of the excretory duet, on the other 
hand, is rarely seen, but may be caused by the impaction o( a renal 
calculus, the pressure of a tumor, or following certain gvnavologie 
operations, in which the ureter is accidentally caught in a suture, etc. 
It has also been suggested that the albuminuria of pregnancy may be 



380 THE URINE. 

due to compression of an ureter, but it is more likely that other 
factors are here at play, such as compression of the renal arteries and 
veins. 

6. Albuminuria of ILemic Origin. — It was formerly supposed 
that Bright' s disease was dependent upon certain abnormalities of 
the blood, and as a matter of fact this view has not only never been 
disproved, but is actually gaining ground from day to day. Accord- 
ing to Semmola, Bright's disease is primarily due to an abnormal 
poAver of diffusion on the part of the albumins of the blood, which 
are eliminated by the kidneys as waste material. As a result of the 
excessive amount of work thus done definite renal changes are finally 
produced. According to his theory, then, the albuminuria is the 
primary factor in the causation of nephritis. Should this hypothesis 
hold good, Senator is correct in asserting that an albuminuria of 
functional origin, so to speak, must precede the occurrence of the 
nephritis proper. He appears to doubt the occurrence of a prene- 
phritic albuminuria, however. In this connection it is interesting to 
note that definite renal changes have actually been observed to fol- 
low an apparently functional albuminuria (Da Costa). Further re- 
searches in this direction are urgently needed, and Sem- 
mola' s view, as well as all others so far proposed, can only be 
regarded as hypotheses. Even if such blood-changes as those 
which Semmola suggests should not exist, there can be little doubt 
that true nephritis is dependent upon an acute or chronic dyscrasia 
of the blood, either in the sense of an abnormal mixture of the nor- 
mal elements or of the presence of abnormal constituents, and notably 
of poisons. The same considerations undoubtedly also apply to vari- 
ous other forms of albuminuria, in so far as these are not the direct 
result of circulatory disturbances. 

Clinically, albuminuria of haeruic origin is observed in various 
diseases of the blood, such as purpura, scurvy, leukaemia, pernicious 
anaemia, as also in cases of poisoning with lead and mercury, in 
syphilis, jaundice, diabetes, following the inhalation of ether and 
chloroform, etc. The albuminuria associated with an excessive 
elimination of uric acid and oxalic acid, and, according to personal 
observations, with an excessive elimination of organic material in 
general, notably of urea, probably also belongs to this class. 

7. Toxic Albuminuria. — It has already been stated that the 
albuminuria of acute febrile diseases may, to a certain extent, be 
referable to a direct irritant action on the part of bacterial poisons 
upon the renal parenchyma. Poisoning with cantharides, mustard, 
oil of turpentine, potassium nitrate, carbolic acid, salicylic acid, tar, 
iodine, petroleum, phosphorus, arsenic, lead, antimony, alcohol, and 
mineral acids produces albuminuria. In all probability, however, 
the albuminuria here observed is referable not only to a direct irri- 



THE CHEMISTRY OF THE URINE. 381 

tant action upon the glandular epithelium of the kidneys, but also to 
circulatory disturbances. 

8. Neurotic Albuminuria. — It is claimed by some that albu- 
min, usually in small amounts, is eliminated in epilepsy after every 
attack, while others either entirely deny its occurrence under such 
conditions or regard it as exceptional. In a number of cases in 
which I had occasion to examine the urine voided after an attack 
albumin was usually absent. It must be stated, however, that the 
seizures in these cases were comparatively slight, and that an exam- 
ination for semen was unfortunately not made in those cases, in which 
traces of albumin could be demonstrated. A recent examination of 
the urine voided by an epileptic, after having been in the epileptic 
state for more than forty-eight hours, showed the presence of a small 
amount of albumin, associated with an enormous elimination of uric 
acid, as well as a large excess of urea. Semen was absent. 

A transient albuminuria has also been noted in cases of progressive 
paralysis, mania, tetanus, delirium tremens, apoplexy, migraine, 
Basedow's disease, brain tumor, etc. 

Although albuminuria may apparently be artificially produced by 
injuries affecting a certain point in the floor of the fourth ventricle, 
analogous to the production of glycosuria (see Glycosuria), it would 
probably be going too far to assume the existence of a certain specific 
centre, stimulation of which would cause the appearance of albumin 
in the urine. While the influence of the nervous system in prevent- 
ing the passage of albumin through the glomeruli under normal 
conditions is undoubted, it would appear more likely that the albu- 
minuria following injuries to the central nervous system is referable 
to circulatory disturbances in the kidneys, secondary to lesions of 
the brain, and especially of the medulla. The albuminuria observed 
in certain neurotic individuals, on the other hand, is probably 
more frequently associated with metabolic abnormalities and of 
hamiic origin. 

9. A Digestive Albuminuria has also been described, but need 
not be considered in detail. Suffice it to say that it may follow the 
ingestion of excessive amounts of cheese, eggs — particularly when 
taken raw, — beef, etc. I have seen albuminuria follow a free in- 
dulgence in root beer. It is, of course, difficult to explain such 
occurrences ; but, bearing in mind the fact that albuminuria very 
often follows the ingestion of such articles almost immediately, ami 
before they have actually had time to become absorbed, it is hardly 
justifiable to refer this form to the existence of a hyperalbuminosis. 
It would appear more rational, as Senator has suggested, to think of 
reflex vasomotor or trophic changes affecting the kidneys : while in 
other cases, in which the albuminuria does not follow the ingestion 
of such articles of food immediately, it is quite probable that this 



382 THE URINE. 

may be dependent upon certain metabolic abnormalities, affecting the 
normal composition of the blood. 1 

In the account thus given, of the occurrence of albuminuria and 
its possible causes, reference has been only had to a purely renal albu- 
minuria. It should be remembered, however, that the origin of the 
albumin may often be extremely difficult to determine, as albuminous 
material, such as blood and pus, may become mixed beyond the 
glandular portion of the kidneys with what Avould otherwise have 
been a perfectly normal urine, and that such an admixture may not 
only take place in the ureters, the bladder, and the urethra, but even 
in the pelvis of the kidney. 

The term accidental albuminuria is applied to a condition in which 
albuminous material becomes mixed with a urine beyond the kidneys, 
which had secreted a normal urine, as in cases of cystitis and 
urethritis, or whenever semen has entered the urine. Such an ad- 
mixture of pus, blood, lymph, or chyle may, however, occur in the 
kidneys, when the albuminuria is termed accidental renal albuminuria, 
an example of which is frequently seen in the slight degree of albu- 
minuria referable to pyelitis, during the convalescence from typhoid 
fever. By a mixed albuminuria and a mixed renal albuminuria, on 
the other hand, we are to understand conditions in which the source 
of the albumin is twofold, renal and extrarenal in the first instance, 
parenchymal and extraparenchymal in the second, examples being the 
albuminuria of cystitis combined with nephritis and pyelonephritis, 
respectively. 

It is manifest, of course, that in every instance in which albumin 
is found in the urine its origin should be ascertained. While this 
question is usually readily decided by a microscopic examination of 
the urine, considerable difficulty may occasionally be experienced. 
It is a well-known fact that in the urine of females a trace of albu- 
min may frequently be detected, which is not due to any lesion of 
the urinary organs, but to an admixture of vaginal discharge, of 
blood, during the process of menstruation, and, in married women, of 
semen. Whenever, therefore, doubt is felt as to the origin of the 
albumin, the specimen for examination should be obtained by the 
catheter, care being taken previously to cleanse the vulva. In males 
albumin may be referable to a gonorrheal urethritis. In such cases 
it is well to let the patient flush out his urethra first, and to make 
use of the portion, last passed, for examination. Very often, how- 
ever, the conditions are more complex, it being uncertain whether 
the albumin is referable to the presence of pus only, or whether its 
origin is in the renal pareuchyma. In such cases, as in cystitis, 
pyelonephritis, etc., a careful microscopic examination, and enumer- 

1 The albumin which is eliminated after the ingestion of much egg-albumin, how- 
ever, does not belong to this category. 



THE CHEMISTRY OF THE URINE. 383 

ation of the pus-corpuscles with the Thoma-Zeiss instrument, is 
called for, and will in the majority of instances decide the question 
(see p. 92). Generally speaking the amount of albumin found in 
uncomplicated cases of cystitis does not exceed 0.15 per cent., while 
in cases of pyelitis of the same intensity the amount of albumin is 
from two to three times as large. 

Of late attention has repeatedly been drawn to the occasional pres- 
ence in the urine of an albuminous body, which is soluble in acetic 
acid, and which Patein regards as a modification of the common 
serum-albumin. It has thus far been observed in only eight cases, 
viz, twice in chronic nephritis, three times in eclampsia, once in a 
cystic kidney, once in tonsillitis, following an injection of diphtheria 
anti-toxin, and once in a pregnant woman, in whom typhoid fever 
developed. I should suggest that the substance be spoken of as 
Patein's albumin until its chemical identity has been thoroughly 
established. The term aceto-soluble albumin is of course likewise 
admissible. 

So far as the amount of albumin which may be eliminated in the 
twenty-four hours is concerned, an excretion of less than 2 grammes 
may be regarded as insignificant, 6 to 8 grammes as a moderate 
amount, and 10 to 12 grammes or more as excessive. An excretion 
of 20 to 30 grammes is very exceptional. 

Serum -globulin. — It has been pointed out that serum-globulin 
is found in the urine together with serum-albumin in large amounts, 
in cases of amyloid degeneration of the kidneys, and, according to 
Senator, a ratio between the two albumins of 1 : 0.8 : 1.4 may be 
regarded as a fairly constant symptom of this disease, and of some 
diagnostic importance. There seems to be no doubt, however, that 
serum-globulin occurs in the urine, although in much smaller quan- 
tities than in the disease mentioned, whenever serum-albumin is 
eliminated, and so far not one case of pure globulinuria has been re- 
ported. This cannot be surprising, as there is no reason why only 
one albumin of the blood should pass through the kidneys. 

Albumoses (peptones). — Albumoses have been frequently ob- 
served in the urine, but are probably more frequently overlooked, as 
the bodies in question are not precipitated on boiling. The factors 
which cause their appearance in the urine are probably similar to those 
noted in connection with peptonuria, and will be presently consid- 
ered. Suffice it to say that traces of albumoses have been observed 
in a great many diseases, such as dermatitis, intestinal ulceration. 
liver-abscess, croupous pneumonia, septicaemia, carcinomatous perito- 
nitis, myxoedema, apoplexy, heart-disease, pleurisy, caries, puerpuraJ 
parametritis, endocarditis, typhoid fever, diphtheria, pyaemia, nephri- 
tis, phthisis, measles, scarlatina, leukaemia, urticaria, acute yellow 
atrophy, various psychoses, etc. Larger amounts are met with in 



384 THE URINE. 

sarcomatosis of the thoracic skeleton, and are thought to be pathog- 
nomonic of this condition. To this form of albumosuria the term 
myelopathic albumosuria has been applied. 

Very frequently albumosuria accompanies albuminuria, consti- 
tuting the so-called mixed albuminuria of Senator. In this connec- 
tion it is interesting to note that albumosuria may alternate with al- 
buminuria, and precede as well as follow the latter, and in any case 
in which albumoses are demonstrable in the urine the appearance of 
albumin should be anticipated. 

Albuminous bodies, which are not coagulated by heat and in their 
general behavior resemble peptones, have repeatedly been seen in urines, 
when Hofmeister's method of testing for peptones was employed, 
and various forms of so-called peptonuria have since been described. 
An elimination of such bodies has been noted in conditions associ- 
ated with large accumulations of pus within the body, and it is sup- 
posed that the peptonuria observed in such cases is referable to a 
disintegration of the pus-corpuscles and a resorption into the blood 
of the peptone contained in these. This form of peptonuria has 
hence been termed pyogenic peptonuria. A hepatogenic form has 
been likewise described in connection with diseases of the liver, 
notably acute yellow atrophy. It was formerly thought that pep- 
tones were retransformed into albumins by the liver, and the occur- 
rence of peptonuria in diseases of this organ was explained by the 
inability on its part to cause this transformation, the peptones accu- 
mulating in the blood and being excreted in the urine. Later re- 
searches, however, have shown that the transformation of peptones 
into albumins takes place in the intestinal mucosa, and that the liver 
apparently has no part in this process ; an explanation of this form 
is therefore wanting. An enter ogenic form has been noted in various 
diseases of the intestinal tract, such as typhoid fever, tubercular 
ulceration, carcinoma, etc., in which it was supposed that peptone is 
either directly absorbed from the disintegrating pus, or that the in- 
testine itself has lost the power of causing its transformation into 
albumin. A histogenic or hcematogenic origin w r as further ascribed to 
the peptonuria seen in cases of scurvy, various forms of poison- 
ing, during the puerperal period, pregnancy, particularly following 
the death of the foetus, in various psychoses, etc. A renal or vesi- 
cal form of peptonuria has finally been noted in which peptones are 
formed in albuminous urines either in consequence of the presence 
of enzymes, or the occurrence of putrefaction. 

More recently, however, since our conception of the nature of 
peptones has changed, — it being quite generally accepted at the 
present day that true peptones are not precipitated by ammonium 
sulphate, — investigations have shown that in all cases in which the 
presence of these bodies had been previously assumed true peptones 



THE CHEMISTRY OF THE URINE. 385 

are actually not present, but that the bodies in question are propep- 
tones or albumoses. According to Kuhne's definition of peptones, a 
peptonuria hence does not exist. 

In the differential diagnosis of suppurative meningitis a positive 
peptone-reaction in the older sense of the word, according to Senator, 
speaks strongly in favor of the existence of this disease. In sup- 
port of this view he cites the case of a young man, the subject of a 
median otitis of long standing, in which symptoms pointing to a 
meningitis, — viz, fever, headache, and pains in the neck, — were pres- 
ent, but in which no " peptonuria " was found to exist, and in which 
an operation revealed the presence of a cholesteatoma. 

A digestive form of albumosuria has recently been announced, 
where albumoses appear in the urine after their ingestion in large 
quantities, and it is claimed that this is only observed in cases of 
ulcerative disease of the intestinal tract. Only a positive result, 
however, is of value. 

Haemoglobin. — Under normal conditions the disintegration of the 
red blood-corpuscles, which is constantly taking place in the body, 
never results in such a degree of hsemoglobinaemia as to be followed 
by an elimination of haemoglobin in the urine. Whenever for any 
reason the destruction of red corpuscles is so extensive, however, 
that the liver is unable to transform into bilirubin all the blood- 
coloring matter set free, hcemoglobinuria will occur. While these 
factors, then — i. e., an excessive destruction of the red blood-cor- 
puscles and an insufficiency on the part of the liver — must be re- 
garded as explaining every case of hemoglobinuria, our knowledge 
of the ultimate causes of such excessive disintegration, as well as 
the manner in which these operate, is as yet very limited. Formerly 
the term hcematinuria was applied to this condition. It was shown, 
however, that the pigment eliminated is in reality not hematin, bat 
usually methemoglobin and only at times haemoglobin, so that the 
term hemoglobinuria is also ill chosen. 

Most frequently to be observed is the hemoglobinuria produced 
by certain poisons, such as potassium chlorate, arseniuretted hydrogen, 
sulphuretted hydrogen, pyrogallic acid, naphthol, hydrochloric acid, 
tincture of iodine, carbolic acid, carbon monoxide, etc., and also by 
morels (Helvella esculenta). 

Quite familiar is the haemoglobin uria which is observed following 
transfusion of the blood of animals into man, such as that of the calf and 
lamb; also the form seen in cases of extensive burns and insolation. 

While hemoglobinuria may occur in the course of any one of the 
specific infectious diseases, such as scarlatina, icterus gravis, variola 
hemorrhagica, typhoid fever, yellow fever, etc., it is said to be espe- 
cially frequent in cases of malarial intoxication. This view is not 
accepted by many, Osier, among others, thinking that it has fre- 
25 



386 THE URINE. 

quently been confounded with malarial hematuria. I have never 
seen a single instance of malarial hemoglobinuria, and believe that 
in our more temperate zones it scarcely ever occurs. Bastianello as- 
serts that it is likewise rare in Italy, but more common in Sicily and 
Greece, and very common in the tropics. According to the same 
observer, hemoglobinuria only occurs in infections with the estivo- 
autumnal parasite. A hemoglobinuria due to quinine is likewise 
said to exist, but is certainly very rare, excepting in patients who 
are suffering, or who have recently suffered, from malarial fever. 
In our country this form is very uncommon. On the other hand, 
there can be no doubt, to judge from the literature upon the subject, 
that syphilis may, under certain conditions, be a potent factor in the 
production of hemoglobinuria. This appears to be particularly true 
of those cases of so-called paroxysmal hemoglobinuria, in which 
bloody urine is voided from time to time, the attacks being frequently 
preceded by chills and fever, so as closely to simulate malarial 
fever. Other factors, also, notably cold, appear to be concerned in 
the production of this form. 

The occasional occurrence of hemoglobinuria in cases of Ray- 
naud's disease, coincident with attacks of an epileptiform character, 
has been referred to in the chapter on Blood (see p. 38). 

Hemoglobinuria has been observed in a case of leukemia com- 
plicated by icterus. 

Finally, an epidemic hemoglobinuria has been described as occur- 
ring in the newborn, associated with jaundice, cyanosis, and nervous 
symptoms ; of its causation we are still in ignorance. 

While hemoglobinuria is fairly uncommon, hcematuria is frequently 
observed, and will be considered later on, as its recognition is not 
dependent upon the demonstration of the albuminous body, " hemo- 
globin/' alone in the urine, but upon the presence of red corpuscles, 
which in hemoglobinuria are either absent or present only in very 
small numbers. 

Fibrin. — The occurrence of fibrin in the urine presupposes the 
presence of fibrinogen, a fibrinogeiric ferment, and probably also of 
serum-globulin; it is seldom seen. According to ^eubauer and Vogel, 
the fibrin may occur either as coagulated fibrin or in solution. In the 
former condition it is at times observed in the form of blood-coagula, 
when its significance is essentially the same as that of hematuria in 
general, although it must be remembered that the usual form of 
hematuria is not associated with the presence of coagula. Colorless 
coagula of fibrin are only seen in cases of chyluria or diphtheritic in- 
flammation of the urinary passages. On the other hand, urines con- 
taining fibrin in solution are likewise seen but rarely, and are 
characterized by the fact that fibrinous coagula separate out only on 
standing, when they usually cover the bottom of the vessel ; but at 



THE CHEMISTRY OF THE URINE. 387 

times they may change the entire bulk of urine into a gelatinous 
mass. So far this condition has been observed only in cases of 
chyluria (which see). 

Nucleo-albumin. — The question whether or not nucleo-albumin 
is a normal constituent of the urine is still a matter of dispute. Per- 
sonal investigations have led me to the conclusion that with compli- 
cated methods and large amounts of urine — from 5 to 25 litres — it 
is always possible to demonstrate its presence, both under physiologic 
and pathologic conditions. With the usual tests and smaller amounts 
of urine, however, negative results only are obtained in strictly nor- 
mal individuals. Trichloracetic acid, with which Stewart claims to 
have obtained positive results in every one of the 150 normal urines 
which he examined, does not precipitate nucleo-albumin, according 
to my experience, when this is present in normal amounts. A nucleo- 
albuminuria, recognizable by the available tests, does not exist under 
normal conditions. Even under pathologic conditions nucleo-albumin 
is by no means always found. Sarzin thus was unable to demonstrate 
its presence in 200 cases, which he examined in Senator's clinic. 
Citron arrived at similar results, and among several thousand urines, 
which I have examined in this direction, positive results were only 
obtained in a very small percentage of cases. Its presence always 
indicates an increased degree of desquamation in some portion of the 
urinary tract. It is essentially met with in diseases which directly 
or indirectly involve the integrity of the epithelial lining of the 
uriniferous tubules or of the bladder. 

It has thus been frequently found in cases of acute nephritis and 
associated with febrile albuminuria, although its presence even then 
is not constant. In chronic nephritis it is more frequently absent 
than present. In cases of renal hyperemia and cystitis the results 
are variable. In thirty-two icteric urines Obermayer obtained pos- 
itive results without exception, and it appears that in leukaemia 
nucleo-albumin is also quite constantly present. During the admin- 
istration of pyrogallol, naphthol, corrosive sublimate, tar prepara- 
tions, arsenic, etc., as well as in cases of poisoning with anilin and 
illuminating gas, large amounts of the substance may be found. 

According to my experience, nucleo-albumin is frequently ob- 
served in cases of so-called functional albuminuria, and it is not at 
all uncommon to find that this is still present when serum-albumin 
and serum-globulin can no longer be demonstrated, oven with the 
trichloracetic acid test. Nucleo-albuminuria may thus exist inde- 
pendently of the presence of the more common forms oi % albumin. 
This observation has also been made by Strauss, who found nucleo- 
albumin only in several cases of cystitis, in one ease o( chronic in- 
terstitial nephritis, and in one case of emphysema pulmonum with 
renal hypersemia. 



388 THE URINE. 

The existence of a hematogenic form of nucleo-albnminuria has 
thus far not been satisfactorily demonstrated. 

Histon. — Quite recently Ivolisch and Burion were able to demon- 
strate the presence of histon in the urine of a case of leukaemia. 
The substance is an albuminous body which was first discovered by 
Kossel in the red blood-corpuscles of the goose, and which was 
shown to exist in the leucocytes of human blood in combination 
with the acid leuko-nuelein, constituting the so-called nucleo-histon 
of Lilienfeld. According to these observers, the substance was 
always present in their case. 

It is not clear in what manner the histonuria is produced ; so 
much, however, seems certain, that it is not solely dependent upon 
the increased destruction of leucocytes. 

A histon-like body has also been found in acute peritonitis, follow- 
ing appendicitis, in croupous pneumonia, erysipelas, and scarlatina. 

Tests for Albumin. — The recognition of the various albuminous 
bodies, which may occur in the urine is based partly upon their 
direct precipitation, and partly upon color-reactions, when treated 
with certain reagents. 

The number of tests which have from time to time been suggested 
is very large ; many of them, after a brief period of use, have been 
discarded as useless or uncertain, while others have been employed 
only occasionally and have not received the recognition which they 
deserved, from the fact that simpler tests existed, that they did not 
possess sufficient delicacy, or that in some instances it was too great. 
In the following pages no attempt will be made to describe all of 
these tests, and attention will be directed only to those which are 
generally used, and which clinical experience has proved to be of 
value, precedence being given to those which have been longest in 
use. AVhile some of these are applicable for demonstrating the 
presence of more than one form of albumin, special tests will also 
be described, whereby the various albumins may be individually 
recognized. 

In every case the urine should be carefully filtered, so as to free 
it from any morphologic constituents, etc., present. To this end it 
is generally sufficient to pass the urine through one or two layers 
of Swedish filter-paper. Frequently, however, a clear specimen 
cannot be obtained in this manner ; it is then advisable to shake the 
urine with magnesia usta or talcum, or to mix it with scraps of filter- 
paper, when it is filtered as usual. 

Tests for Serum -albumin. — The Xiteic-acid Test. (Fig. 95.) 
The value of this test, properly applied, cannot be overestimated, as 
it is not only simple, but yields an amount of information that can 
otherwise only be gained with difficulty. Usually the student is 
advised to make use of a test-tube partially filled with urine, along 



THE CHEMISTRY OF THE UBIJSE. 



389 



Fig. 95. 



the sides of which concentrated, chemically pure nitric acid is allowed 
to flow, so as to form a layer at the bottom of the tube, when, in the 
presence of serum-albumin, a distinct 
white cloud will appear in the form of 
a ring, at the zone of contact between 
the two liquids (Heller's test). The 
pictures thus obtained cannot be com- 
pared, however, with those seen when 
the apparently trivial change is made 
of using a conical glass of about 2 
ounces capacity instead of the test- 
tube. About 20 c.c. of urine are placed 
in the glass, and 6 to 10 c.c. of nitric 
acid added by means of a pipette, 
which is carried to the bottom of the 
vessel, when the acid is slowly allowed 
to escape by diminishing the pressure 
of the finger upon the tube. When 
this is carefully done, as in Heller's 
test, the nitric acid forms a distinct 
zone beneath the urine. In the pres- 
ence of albumin the cloud referred to 
will be seen, its extent and intensity 
varying with the amount of albumin 
present (Plate XIV., Fig. 1). If now 

the glass is allowed to stand for some time, — and if small amounts are 
present, these only appear on standing for several minutes, — it will 
be observed that the cloudiness gradually extends upward, and if 
much albumin is present this may be seen to rise into the supernatant 
liquid in the form of small, irregular columns. This appearance is 
possibly referable to the partial decomposition of uric acid by means 
of nitric acid, nitrogen and carbon dioxide being set free, which, 
rising to the surface in the form of small bubbles, carry the nitric 
acid upward ; coming into contact with albumin in solution this then 
causes the precipitation of the latter. An excess of uric acid, more- 
over, is indicated by the appearance, within five to ten minutes after 
the addition of the nitric acid, of a distinct ring in the clear urine, 
about 1 to 2 cm. above the zone of contact, which is similar in ap- 
pearance to that due to albumin. If this ring (Plate XIV.. Figs. 1, 
2, and 3), which has been very appropriately compared to a holy 
wafer, does not appear within five to ten minutes, it may be assumed 
that the uric acid is present in diminished amount ; on the other 
hand, it is possible to determine the degree of increase by the size 
of the ring, it being presupposed that the same quantities of urine 
and of the reagent are employed in every ease. 




Nitric acid test. 



390 THE URINE. 

Should more than 25 grammes of urea be contained in a litre of 
the urine examined, an appearance like hoarfrost will be noted on 
the sides of the vessel, which is due to the formation of urea nitrate. 
Spangles of the same substance only appear in the presence of at 
least 45 grammes, and if 50 grammes or more of urea are contained 
in the litre, a dense mass of urea nitrate may be seen to separate 
out. 

Biliary urine, when treated with nitric acid containing a little 
nitrous acid, shows the color-play referable to the action of nitric acid 
upon bilirubin (Plate XIV., Fig. 4); the production of the colors, 
yellow, green, blue, violet, and red, takes place from above down- 
ward, the green color being the most characteristic ; in the absence of 
the latter the presence of biliary pigment may be positively excluded. 
The presence of albumin is not at all objectionable, as the color-play 
takes place beneath the albuminous disk. 

In normal urine a transparent, colored ring is also obtained, pre- 
senting a peach-blossom red ; the intensity of this may vary, how- 
ever, from a faint rose to a pronounced brick color, and is referable 
to normal urinary pigment (Plate XIV., Fig. 5). In the presence of 
urobilin, on the other hand, this ring presents a distinct mahogany 
color. 

Indican is indicated by the appearance of a ring (Plate XIV., Fig. 
2), which is more or less violet, and situated above that referable to 
the normal urinary pigment. Its intensity varies, with the amount 
present, from a light blue to a deep indigo-blue. 

A cloud at the zone of contact of the two fluids may be referable, 
not only to the presence of serum-albumin, but also of globulin and 
albumoses (propeptones), while a negative reaction will generally 
indicate the absence of these bodies. That the uric-acid ring will 
be mistaken for albumin is hardly likely, if it is remembered that 



DESCRIPTION TO PLATE XIV. 

Fig. 1. The nitric-acid test as applied to the urine : The light, colorless ring in the 
clear urine above shows a slight increase in the amount of uric acid ; the large white 
band denotes a large amount of albumin, bordering upon a colored ring, referable 
partly to indican (blue) and partly to urorosein. 

Fig. 2. The nitric-acid test as applied to the urine : The light ring in the clear 
urine above denotes a slight increase in the amount of uric acid. The bluish-black 
band is referable to an enormous increase in the amount of indican. Taken from a 
case of ileus. 

Fig. 3. The nitric-acid test as applied to the urine : The broad, light band in the 
clear urine above is referable to an enormous increase in the amount of uric acid. 
Taken from a case of laparotomy. 

Fig. 4. The nitric-acid test as applied to the urine : The color-play referable to the 
presence of bilirubin is shown in a diagrammatic manner. 

Fig. 5. The nitric-acid test as applied to the urine : The colored ring is referable to 
the presence of normal urinary coloring matter. 



fetattto, 



PLATE XIV. 



FIG. 2. 



FIG. 4. 




FIG. 1. 



FIG. 3. 




FIG. S. 



THE CHEMISTRY OF THE URINE. 391 

this never first appears at the zone of contact of the two fluids, but 
always in the uppermost portion of the urine. It is true that urines 
are occasionally observed, in which the separation of uric acid, always 
in the amorphous form, takes place so suddenly, that within a minute 
or two the entire urinous portion of the mixture is completely 
clouded, resembling the appearance presented by a highly albuminous 
urine. Such an excessive elimination of uric acid is quite uncom- 
mon, however, and it is to be remembered that with uric acid the 
cloudiness proceeds from above downward, and never from below 
upward, as is the case with albumin. Should any doubt be felt, it 
is only necessary to remove a few c.c. of this cloudy urine by means 
of a pipette and to heat it gently in a test-tube, when the urine will 
clear up entirely, if the precipitate is due to uric acid, while, if caused 
by albumin, it will remain or become still more intense. Should the 
precipitate caused by nitric acid consist of albumoses, this will also 
clear up entirely, to reappear on cooling, the fluid at the same time 
assuming a distinct yellow color. The occurrence of a distinctly 
yellow color in the urine, moreover, which is only partially cleared 
upon the application of heat, and be it remembered that a much 
higher temperature is necessary for the solution of a precipitate refer- 
able to albumoses than of one due to urates, will indicate the exist- 
ence of a mixed albuminuria — i. e., the presence of coagulable albumin 
and albumoses. Nitric acid may also cause a precipitation of certain 
resinous bodies, such as those contained in turpentine, balsam of 
copaiba and tolu, etc. If any doubt is felt, the mixture should be 
shaken with alcohol, when the precipitate caused by these substances 
is at once dissolved. The mucinous body — nucleo-albumin — which 
is at times found in the urine, is also precipitated by nitric acid, but 
need not occupy our attention at this place. From what has been 
said it is manifest that the employment of the nitric-acid test, in the 
manner indicated, furnishes much valuable information, and the 
adoption of the method, as described, not only by hospital stu- 
dents, but by general practitioners as well, cannot be too strongly 
urged. 

Boiling Test. — A few c.c. of urine are boiled in a test-tube and 
then treated with a few drops of concentrated nitric acid, no matter 
whether a precipitate has occurred upon boiling or not. If albumin 
is present, this will separate out as a flaky precipitate, which consists 
of serum-albumin, frequently mixed with serum-globulin. It is 
true that albuminous urines will generally yield a precipitate on boil- 
ing alone, but it must be remembered that, unless the reaction is de- 
cidedly acid, a precipitation of normal calcium phosphate may occur, 
owing to the fact that the reaction of the urine upon boiling becomes 
less acid from an escape of the carbonic acid held in solution. 
In urines presenting an alkaline or amphoteric reaction this is very 



392 THE URINE. 

frequently noted, and might give rise to confusion, as the precipitate, 
due to calcium phosphate, very closely resembles that referable to 
albumin. Care must hence be taken to insure a distinctly acid reac- 
tion, which is best accomplished by the addition of nitric acid, when 
a precipitate referable to phosphates is at once dissolved, while one 
due to albumin remains, and may even become more marked. The 
quantity to be added should usually be equivalent to about 0.05 to 
0.1 of the volume of the urine. Under no consideration should the 
acid be added before boiling, nor should the urine be boiled after its 
addition, as small amounts of albumin will otherwise be overlooked, 
owing to the fact that hot nitric acid dissolves the precipitate to a 
certain degree. If, after the addition of the nitric acid, the urine 
turns a distinct yellow, and if then upon cooling a white precipi- 
tate appears, the presence of albumoses may be inferred. Uric acid 
will probably never cause confusion, as this only separates out upon 
cooling, and then presents a dark-brown color. As in the case of 
the nitric-acid test, so also here, a precipitation of certain resins is 
noted at times ; these may be recognized by their solubility in alco- 
hol. Albumoses are also precipitated upon the application of heat, 
but such precipitates again dissolve when the temperature approaches 
the boiling point (see p. 391). 

Should acetic acid be used instead of nitric acid, great care must 
be taken to avoid an excess, as otherwise the albumin will be dis- 
solved. As this danger diminishes the greater the quantity of salts 
contained in the urine, it is advisable to treat the urine, first with a 
few drops of acetic acid until a distinctly acid reaction is obtained, 
and then to add one-sixth of its own volume of a saturated solution 
of sodium chloride, magnesium sulphate, or sodium sulphate, when 
upon boiling a precipitation of the albumin will occur. Carried 
out in this manner, the test is absolutely certain and will dem- 
onstrate even minimal amounts of albumin. If an equal volume 
of a saturate solution of common salt is added to the acidified urine 
albumoses are also precipitated, but the precipitate dissolves on 
boiling. 

The Potassium Fereocyanide Test. — A few c.c. of urine are 
strongly acidified with acetic acid (sp. gr. 1.064) and treated with a 
few drops of a 10-per-cent. solution of potassium ferrocyanide, when, 
in the presence of but little albumin, a faint turbidity, or, if much 
albumin is present, a flaky precipitate, is noted, which is best recog- 
nized by comparison with a tube containing some of the pure filtered 
urine, both tubes being held against a black background. Concen- 
trated urines should be previously diluted with water, as albumoses, 
like serum-albumin and serum-globulin, which may be precipitated 
in this manner, otherwise remain in solution. Here, also, as in the 
tests described, the presence of albumoses may be inferred, if the 



THE CHEMISTRY OF THE URINE. 393 

precipitate disappears upon boiling, while a partial clearing up, on 
the other hand, indicates the presence of both albumoses and coagu- 
lable albumin. 

At times the addition of acetic acid by itself is followed by the 
appearance of a cloud in the urine, which may be due to urates or to 
urinary mucin (nucleo-albumin), as already mentioned. In such 
cases the urine should be refiltered, diluted with water, and the test 
again applied. 

v. Jaksch advises the careful addition, by means of a pipette, of a 
few c.c. of fairly concentrated acetic acid, to which a little potassium 
ferrocyanide has been added, when the albumin, as in Heller's test, 
is seen to form a ring at the plane of contact between the two fluids. 
Instead of potassium ferrocyanide, potassium platinocyanide may 
also be employed, and has the advantage that the test-solution is 
colorless. 

The Thichloracetioacid Test. — This test is undoubtedly the 
most delicate of those so far described, but not so delicate that a 
trace of albumin, or nucleo-albumin, as has been suggested by some, 
can be demonstrated in every urine. An experience based upon the 
examination of several thousand urines with this reagent warrants 
my speaking with a certain amount of confidence upon the subject. 
Very frequently it is possible with this method to demonstrate 
albumin in urines, in which the more common tests yield negative 
results, but in which tube-casts may nevertheless be found upon 
microscopic examination. The test is applied as follows : By 
means of a pipette, 1 or 2 c.c. of an aqueous solution of the reagent 
(sp. gr. 1.147) are carried to the bottom of a test-tube, containing 
the carefully filtered urine, so as to form a layer beneath the urine. 
In the presence of albumin, a white ring will be seen to form at the 
zone of contact between the two fluids, varying in intensity with the 
amount of albumin present. So far as the test for albumin is con- 
cerned, this reagent possesses an advantage over the nitric acid in 
that the colored rings, which are so often confusing to the inexperi- 
enced, are but rarely observed. Serum-albumin, serum-globulin, 
and albumoses are thus precipitated, the presence of the latter being 
recognized, as in the previous tests, by the fact that the precipitate 
disappears upon boiling and reappears on cooling. A cloud, refer- 
able to uric acid, also appears, if this is present in excessive amounts. 
but it is readily distinguished from that caused by albumin by the 
fact that it disappears upon the application of gentle heat. A pre- 
vious dilution of the urine, moreover, guards against this occur- 
rence. 

Other tests have also been suggested for the detection o\^ albumin 
in the urine, such as the metaphosphoric-acid test, the phenol, tannie- 
acid, and picric-acid tests, that with Tan vet's reagent, phospho- 



394 THE URINE. 

tungstic and phospho-molybdic acids, and quite recently Spiegler's 
reagent. 

Of these, only the picric-acid and Spieglers test will be con- 
sidered. 

Picric-acid Test. — The picric-acid test is not applicable as a 
test for albumin as such, and is only mentioned in this connection, 
because Esbach's quantitative method is based upon it. His reagent 
is composed of 10 grammes of picric acid and 20 grammes of crys- 
tallized citric acid, dissolved in a litre of distilled water. If to this 
solution albuminous urine is added, the mixture is rendered turbid, 
and after some time a sediment which consists not only of albu- 
mins, but also of uric acid, kreatinin, and other extractives, will 
form at the bottom of the tube (see Quantitative estimation of 
albumin). 

Spiegler's Test. — Spieglers reagent consists of 8 parts by 
weight of mercuric chloride, 4 parts of tartaric acid, and 200 parts 
of water, in which 20 parts of cane-sugar are further dissolved, so 
as to increase the specific gravity of the reagent and permit of its 
being employed, like Heller's test, even in concentrated urines. 
One-third of a test-tube is filled with the reagent, and the urine 
carefully placed above this by allowing it to flow slowly down the 
side of the tube ; in the presence of albumin a sharply defined white 
ring will be observed where the two liquids are in contact. Peptone 
gives no reaction, while albumoses are precipitated and may be recog- 
nized as indicated above. 

Special Test for Serum-albumin. — Should it be desired, for 
any reason, to demonstrate serum-albumin alone, the urine is ren- 
dered amphoteric or faintly alkaline with sodium hydrate, and then 
saturated with magnesium sulphate in substance, in order to remove 
any globulin. The filtrate is strongly acidified with acetic acid, 
when a flaky precipitate, appearing upon boiling, will indicate the 
presence of serum-albumin. 

Patein's albumin differs from the common serum-albumin in being 
soluble in acetic acid. 

Very often, as in the examination for sugar, it is necessary to re- 
move any coagulable albumin that may be present, to which end the 
urine is rendered distinctly acid with acetic acid and boiled. An ex- 
amination of the filtrate with potassium ferrocyanide, if the amount 
of acetic acid added was just sufficient, will then yield a negative re- 
sult (see p. 392). 

Quantitative Estimation of Albumin. — For the quantitative esti- 
mation of albumin a number of methods have been devised, which 
fact in itself is sufficient to indicate that the majority of these, at 
least, are unsatisfactory. 

Old Method by Boilixg. — If only comparative results are to 



THE CHEMISTRY OF THE URINE. 395 

be obtained, the old method of boiling a definite amount of urine, 
after the addition of acetic acid, and allowing the albumin to settle 
for twenty-four hours, may be employed. For this purpose Xeu- 
bauer suggests the use of glass tubes, measuring one-half to three- 
quarters of an inch in diameter, which are closed at the lower end 
with a cork. Ordinary test-tubes answer the purpose perfectly well, 
but care should be taken that the same quantity of urine is used in 
every case. These tubes may then be corked and kept for several 
days for comparison. The results, of course, only express the rel- 
ative amount of albumin present, and it should be remembered that 
the error incurred may amount to as much as 30 or even 50 per 
cent, of the quantity that is found by gravimetric analysis. This 
is owing to the fact that sometimes the albumin separates out in large 
flakes, and at other times in small flakes, and that the degree of 
precipitation is also influenced by the specific gravity of the super- 
natant urine. 

Volumetric Method of Wassiliew. — This method can be 
strongly recommended for the quantitative estimation of albumin, as 
it is both simple and accurate. 

Ten to twenty c.c. of urine, which are best diluted to 50 c.c. with 
distilled water, are treated with 2 drops of a 1-per-cent. aqueous 
solution of true yellow, and then titrated with a 25-per-cent. solution 
of salicyl-snlphonic acid, until a distinct brick-red color is obtained. 
The number of c.c. employed, multiplied by 0.01006, will indicate 
the amount of albumin in the 10 or 20 c.c. of urine examined. If 
the urine is alkaline, it should first be slightly acidified with acetic 
acid. 

Esbach's Method. — For clinical purposes, Esbach's method is 
the most convenient. As stated above, his reagent is composed of 
10 grammes of picric acid and 20 grammes of citric acid, dissolved in 
1,000 c.c. of distilled water. Special tubes, termed albuminimeters 
(Fig. 96), are employed, which bear two marks, one, U, indicating 
the point to which urine must be added, and one, JR, the point to 
which the reagent is added. The lower portion of the tube up to U 
bears a scale reading from 1 to 7. The tube is filled to ETwith the 
filtered albuminous urine, and the reagent added until the point R is 
reached. The tube is then closed with a stopper, inverted twelve 
times, and set aside for twenty-four hours. At the expiration of this 
time serum-albumin, serum-globulin, and albnmoses, as well as uric 
acid and kreatinin, will have settled down, when the amount pro 
mille, in grammes, may be directly read off from the scale. .V few 
precautions must, however, be observed in order to obtain as accurate 
results as possible. The reaction of the urine should he acid, and 
if such is not the ease acetic acid is added. Its specific gravity 
should, furthermore, not exceed 1.006 or 1.008, the proper density 



396 



THE URINE. 



Fig. 96. 



being obtained by diluting with water. The temperature also ap- 
pears to play an important role, the reading generally being higher 
with a low than with a more elevated temperature; 15° 
C. is best adapted to our purpose. 

The Differential Density Method. — More ac- 
curate results may be obtained with the following method, 
which is based upon the diminution in the specific gravity 
of the urine after the removal of all albumin, and its 
comparison with the specific gravity observed before. To 
this end the urine is treated with a sufficient amount oi 
acetic acid to insure a complete precipitation of the albu- 
min (see below), when its specific gravity is noted. It is 
then brought to the boiling-point, care being taken to 
guard against evaporation by placing the urine in an ordi- 
nary medicine-bottle ; this is closed with a rubber stopper 
that has been previously boiled in a solution of sodium 
hydrate and washed until free from an alkaline reaction, 
the stopper being tightly fastened with a cord or wire. 
Thus prepared, the bottle is kept in boiling water for ten 
to fifteen minutes. The urine is then filtered on cooling, 
evaporation being again carefully guarded against by 
filtering into a bottle through a funnel, which has been 
passed through a closely fitting stopper ; the funnel is 
kept covered by a plate of glass. The specific gravity is 
then again determined, and it is best in both cases to use 
a pyknometer. The decrease in the specific gravity, mul- 
tiplied by 400, will indicate the number of grammes of albumin in 
100 c.c. of urine. 

Gravimetric Method. — If special accuracy is required, the 
amount of albumin must be determined gravimetrically as follows : 
A certain amount of urine, after having been acidified with acetic 
acid, so as to insure a complete precipitation of all albumin, is boiled ; 
the albumin is then filtered off, dried, and weighed. For this pur- 
pose, 500 to 1,000 c.c. of carefully filtered urine should be available. 
A specimen of this, if already acid, is placed in a test-tube, in boiling 
water, until coagulation takes place, when it is further heated over 
the free flame and filtered. The filtrate is then tested with acetic acid 
and potassium ferrocyanide. Should no albumin be thus demonstra- 
ble, the entire amount of urine is treated in the same manner and 
requires no further addition of acetic acid. If, however, the test 
yields a positive result, it is apparent that the urine was not suffici- 
ently acid. The entire volume is then treated with a 30- to 50-per- 
cent, solution of acetic acid, drop by drop, the mixture being thor- 
oughly stirred and specimens tested from time to time, as described. 
When, finally, the urine remains clear or shows only a faint turbid- 



Esbaclrs al- 
buminimeter 



THE CHEMISTRY OF THE URINE. 397 

ity, 100 c.c. or less, according to the amount of albumin present, are 
first heated in boiling water, until the albumin begins to separate out 
in flakes, and then carefully brought to the boiling-point over the 
free flame. The supernatant urine is decanted through a filter, dried 
at 120° to 130° C, and accurately weighed, when the whole amount 
of the precipitate is itself brought upon the filter. Any albumin 
remaining in the beaker is detached from its sides by means of a 
glass rod, tipped with a piece of rubber-tubing, and collected 
by the aid of hot water. With this the entire precipitate is now 
thoroughly washed, until the washings no longer become turbid, 
when treated with a drop of nitric acid and silver nitrate, in other 
words, until the chlorides have been completely removed. The pre- 
cipitate is further washed with alcohol and finally with ether to re- 
move any fats that may be present, when it is dried at 120° to 130° 
C, until a constant weight is reached. If still greater accuracy is 
required, the dried and weighed precipitate is now incinerated to 
determine the amount of mineral ash in combination with the al- 
bumin, which is then deducted from the previous weight. The best 
results are obtained, if not more than 0.2 to 0.3 gramme of albumin 
is contained in the amount of urine employed, so that a smaller 
quantity than 100 c.c. should be used, if a previous test with Es- 
bach's albuminimeter shows a higher percentage. 

A glass-wool filter insures a more rapid process of drying — twenty- 
four to thirty hours ; but care must then be had that this is properly 
prepared, so as to guard against a loss of the wool while washing. 

Test for Serum -globulin and its Quantitative Estimation. — To test 
for serum-globulin the urine is rendered alkaline by the addition of 
ammonium hydrate, any phosphates that may thus be thrown down 
being filtered off on standing. The urine is then treated with an 
equal volume of a saturated solution of ammonium sulphate, when 
the occurrence of a precipitate will indicate the presence of the glob- 
ulin. Ammonium urate, which may likewise separate out, can al- 
ways be recognized by its color. 

According to Paton, the following test may also be emploved : The 
urine after having been rendered alkaline with sodium hydrate, — 
any phosphates which may separate out are filtered off, — is care- 
fully poured down the side of a test-tube containing a saturated solu- 
tion of sodium sulphate, so as to form a layer above this, when in 
the presence of serum-globulin a white ring will appear at the zone 
of contact. 

If a quantitative estimation of the globulin is to be made, the pre- 
cipitate thus obtained, after about one hour's standing, is collected 
on a dried and weighed filter, and washed thoroughly with a one- 
half saturated solution of ammonium sulphate, until a specimen 
of the washings treated with acetic acid and potassium ferrocy- 



398 THE URINE. 

anide no longer gives a precipitate. It is then treated as directed 
in the method employed for the quantitative estimation of serum- 
albumin. 

Tests for Albumoses. — A small amount of urine is strongly acidified 
with acetic acid and treated with an equal volume of a saturated so- 
lution of common salt. In the presence of albumoses a precipitate 
occurs, which dissolves on boiling and reappears on cooling. If 
serum-albumin should also be present, which is usually the case, 
the hot liquid must be filtered. The albumoses are found in the 
filtrate and appear on cooling. If the hot filtrate, moreover, is ren- 
dered alkaline with a solution of sodium hydrate, a red color de- 
velops upon the addition of a very dilute solution of copper sulphate, 
added drop by drop (biuret reaction). On boiling with Hilton's re- 
agent a red color is also obtained. This reagent is prepared by 
dissolving one part of mercury in two parts of nitric acid, of a 
specific gravity of 1.42, and diluting with two volumes of distilled 
water. 

Further tests for albumoses have already been described in connec- 
tion with the common tests for serum-albumin. 

Test for Peptones. — That peptones in the sense of Kuhne do not 
occur either in normal or pathologic urines has already been pointed 
out, and the methods to be described have therefore reference only 
to peptone in the older sense of the word. 

Salkowski's Method. — Fifty c.c. of urine are acidified in a 
beaker with 5 c.c. of hydrochloric acid, and precipitated with phos- 
photungstic acid, the mixture being heated over the free flame, when 
in a few minutes the precipitate will form a resinous mass, which 
closely adheres to the bottom of the vessel. The supernatant fluid 
is decanted, and the mass at the bottom, which now becomes granular, 
washed twice with distilled water, which is likewise removed by 
decantation. The precipitate is then covered with about 8 c.c. of 
distilled water, and treated with 0.5 c.c. of a sodium hydrate solu- 
tion (sp. gr. 1.16). Upon shaking the beaker the mass will dissolve, 
the solution assuming a dark-blue color. This is heated on the free 
flame until the blue color turns to a dirty, grayish-yellow ; the solu- 
tion at the same time becomes turbid, but at times may turn yellow 
and remain clear. This discoloration may be hastened by the further 
addition of a few drops of sodium hydrate solution. As soon as 
this point has been reached, some of the liquid is placed in a test- 
tube, allowed to cool, and then treated with a very dilute solution 
of copper sulphate (1 to 2 per cent.) drop by drop ; in the presence 
of peptones the solution assumes a bright-red color, which may be 
brought out still more strongly, if the specimen is now filtered. If 
albumin or much mucin is present, these bodies must first be re- 
moved (see p. 394 and below) ; but the quantity of urine employed 



THE CHEMISTRY OF THE URINE. 399 

is so small that the mucin can usually be disregarded. With this 
method, which occupies only about five minutes, 0.015 gramme of 
peptones pro 100 c.c. may be demonstrated without difficulty. 

Salkowski has recently pointed out that urines which are very 
rich in urobilin, as in pneumonia, may give rise to the biuret-reac- 
tion, even when albumoses are absent. The coloring-matter, it is 
true, may be removed entirely by precipitation with acetate or sub- 
acetate of lead, but a portion of the albumoses unfortunately is also 
carried down, and the substance may thus escape detection, when 
present only in small amounts. He hence suggests that smaller 
quantities of urine, such as 10 c.c, be employed in the test. The 
reaction is then not so well marked, but the results are more re- 
liable. 

Bang's Method. — This method has recently been introduced 
and is said to be free from the objections attaching to the one pro- 
posed by Salkowski. Ten cubic centimetres of urine are heated in 
a test-tube with eight grammes of finely powdered ammonium sul- 
phate until the salt has been dissolved, and boiled for a moment. 
The hot fluid is then centrifugated for one-half to one minute, the 
supernatant fluid poured off and the sediment rubbed up with 
alcohol in an agate mortar. The alcohol is poured off, the residue 
dissolved in a little water, boiled, filtered, and the filtrate tested with 
sodium hydrate solution and copper sulphate as described. Should 
the urine be especially rich in urobilin, i. e., manifesting a well- 
marked fluorescence with zinc chloride and ammonia, it is best to 
extract the final aqueous solution with chloroform, by shaking, to re- 
move the chloroform, and then to test with copper sulphate. In this 
manner it is possible to demonstrate the presence of albumoses in a 
dilution of 1 : 4000-5000. Other constituents of the urine, with 
the exception of hsematoporphyrin, do not interfere with the test. 
Should this be present, however, which may be suspected, if a red 
alcoholic extract is obtained, the urine must first be precipitated with 
barium chloride. The filtrate, which contains the albumoses is then 
examined, as described. 

If a centrifuge is not available the urine is boiled with the ammo- 
nium sulphate, when a portion of the albumoses will remain on the 
sides of the tube, as a sticky mass. This is washed with alcohol, 
and if necessary with chloroform, dissolved in water, and tested for 
biuret. 

The alcoholic extract may also be used for testing for urobilin. 
To this end it is only necessary to add a few drops of a solution ot % 
zinc chloride, when in the presence of urobilin a beautiful fluores- 
cence will be observed. The tost is extremely delicate. 

Tests for (Mucin) Nucleo-albumin. — The carefully filtered urine is 
treated in a test-tube, drop by drop, with an excess of concentrated 



400 THE URINE. 

acetic acid, when the occurrence of a turbidity will indicate the 
presence of nucleo-albumin. 

If the urine contains albumin, this must first be removed, simple 
boiling being sufficient. Dilution of the urine (1 part to 3 of water) 
should also be practised when any doubt is felt, as urates will then 
not interfere with the reaction, nor will the urinary salts be so apt to 
exert a solvent action upon the mucin, if they are present in large 
amounts. 

Ott's test may also be advantageously employed. To this end a 
few c.c. of urine are treated with an equal volume of a saturated 
solution of common salt, when Almen's solution, which consists 
of 5 grammes of tannic acicl, 10 c.c. of a 25-per-cent. solution of 
acetic acid, and 240 c.c. of 40- to 50-per-cent. alcohol, is slowly 
added. In the presence of nucleo-albumin a precipitate develops 
at once. 

Nucleo-albumin is characterized by its insolubility in acetic acid, 
in the fact that it is precipitated by magnesium sulphate, and that it 
does not give rise to the formation of a reducing substance, when 
boiled w T ith dilute acids. It is thus readily distinguished from 
globulin and true mucin, with which it has frequently been con- 
founded. Globulin precipitates are easily soluble in acetic acid, and 
mucin, when boiled with acids, gives rise to the formation of a re- 
ducing substance. 

In order to remove nucleo-albumin from the urine this is treated 
with neutral acetate of lead, an excess of the reagent being carefully 
avoided. If it is desired to test for peptones, the filtrate is then 
treated with hydrochloric acid and the process continued, as described 
above. 

Test for Haemoglobin. — The diagnosis of hemoglobinuria is based 
upon the demonstration of haemoglobin, viz, methaemoglobin, in the 
urine in solution, in the absence of red corpuscles, or at least in the 
presence of only a very small number, so that an examination in the 
latter direction is also an important factor. 

Bloody urine is generally turbid and may vary in color from 
bright-red to almost black. 

Oxyhemoglobin, as such, can only be recognized by the spec- 
troscope, giving rise to the appearance of two bands of absorption, 
situated between D and E, as described in the chapter on the 
Blood. 

The urine to be examined spectroscopically should be rendered 
feebly acid by means of acetic acid, and placed before the open slit 
of the spectroscope in a test-tube, beaker, or similar vessel, when the 
two bands of oxyhemoglobin will be seen, either at once, or upon 
carefully diluting with distilled water. If ammonium sulphide is 
now added, the spectrum of reduced haemoglobin will be obtained. 



THE CHEMISTRY OF THE URINE. 401 

It must be remembered, however, that more commonly the spectrum 
of methsemoglobin is seen in cases of hemoglobinuria. 

The following tests, which will also indicate the presence of blood 
coloring-matter, cannot be employed to decide the nature of the pig- 
ment present, as methsemoglobin and oxyhemoglobin will both react 
in the same manner. 

Heller's Test. — A small amount of the urine, or still better a 
portion of the sediment, is made strongly alkaline with sodium hy- 
drate, and boiled. On standing a deposit of basic phosphates forms, 
which in the presence of blood coloring-matter presents a bright red 
color. This is referable to the formation of hsemochromogen, as may 
be shown by spectroscopic examination. Thus controlled the test is 
extremely sensitive, and still yields a positive result, when the chem- 
ical test alone leaves in doubt. The deciding band is the first be- 
tween D and E. Care should be had, however, that the solution is 
cold, as otherwise the hsemochromogen is transformed into hsematin — 
in alkaline solution. At times, when the urine contains a large 
amount of coloring matter (bile pigment, etc.), it may be difficult to 
appreciate the exact color of the sediment. In such cases the sub- 
sequent examination with the spectroscope, — the lensless instrument 
of Hering, or that of Browning suffices, — is invaluable. In the 
absence of such apparatus the procedure of v. Jaksch may be em- 
ployed. To this end the phosphatic deposit is filtered off and dis- 
solved in acetic acid, when, if blood pigment is present, the solution 
becomes red, and the color gradually vanishes upon exposure to the 
air. 

The Guaiacum Test. — A mixture of equal parts of tincture of 
guaiacum and oil of turpentine, which has been ozonized by exposure 
to the air, is allowed to flow carefully along the side of a test-tube 
upon the urine to be examined, in such a manner as to form a dis- 
tinct layer above the urine. In the presence of blood-pigment a 
white ring, which gradually turns to blue, will be seen to form at the 
surface of contact. 

Test for Fibrin. — Fibrin usually occurs in the urine in the form 
of distinct clots, the nature of which may be determined by thor- 
oughly washing them with water, when they are dissolved by boil- 
ing in a 1-per-cent. solution of soda or a 5-per-cent. solution of hy- 
drochloric acid. Upon cooling, this solution is then tested as for 
serum-albumin. 

Test for Histon. — The urine of twenty-four hours is first examined 
for albumin, and this removed, if present. It is then precipitated 
with 94-per-cent. alcohol, the precipitate washed with hot alcohol 
and dissolved in boiling water. Upon cooling, the solution thus 
obtained is acidified with hydrochloric acid and allowed to stand for 
several hours. During this time a cloudiness, referable to a large 
26 



402 THE URINE. 

extent to uric acid, develops, which is filtered off, when the filtrate is 
precipitated with ammonia. In addition to certain mineral constitu- 
ents, histon, if present, is also thrown down. The precipitate is col- 
lected on a small filter and washed with ammoniacal water until the 
washings no longer give the biuret reaction. It is then dissolved in 
dilute acetic acid and the solution tested with the biuret test ; if this 
yields a positive result, and if coagulation occurs upon the applica- 
tion of heat, the coagulum being soluble in mineral acids, the pres- 
ence of histon may be inferred. 

Carbohydrates. 

The carbohydrates which may occur in the urine are glucose, lac- 
tose, maltose, dextrin, levulose, certain pentoses and animal gum. 

Glucose. — Through the researches of Wedenski, v.Udranszky a. o., 
we now know that traces of glucose may be encountered in the urine 
under strictly normal conditions. The amount, however, is extremely 
small, and special methods are necessary in order to demonstrate its 
presence. With the usual clinical tests normal urine is apparently 
free from sugar, unless unduely large amounts have recently been 
ingested. In that event a certain amount of glucose is eliminated 
in the urine, constituting the so-called digestive glycosuria of Claude 
Bernard. 

The normal limit to the assimilation of glucose on the part of the 
body economy is subject to considerable variation. Some observers 
thus report that the ingestion of such large amounts, as two hundred 
and two hundred and fifty grammes, does not lead to glycosuria, 
while others have found sugar in the urine after the administration 
of one hundred grammes. In view of the possible relation existing 
between diabetes and a lowered limit to the assimilation of glucose 
in apparently normal individuals, or at least in persons, in which 
glucose cannot be constantly demonstrated in the urine, this 
question has created much interest within the last few years and 
called forth a vast amount of work. The majority of investiga- 
tors are now in accord in regarding a glycosuria that follows the 
ingestion of one hundred grammes of chemically pure glucose as ab- 
normal. 

The method which is usually employed in order to ascertain the 
power of assimilation for glucose on the part of an individual is the 
following : 

The patient receives 100 grms. of glucose, in substance, dissolved 
in 500 c.c. of water, on an empty stomach, and is instructed to pass 
his water hourly during the following four to five hours. During 
this time, moreover, no food is to be taken. The individual speci- 
mens, as well as the urine which has been passed during the night, 



THE CHEMISTRY OF THE URINE. 403 

are then tested with Tro turner's and ~Ny lander's test, with the fer- 
mentation test and with phenyl-hydrazin. A positive result, how- 
ever, is only recorded, when sugar can be demonstrated with the fer- 
mentation test. 

Cane sugar and larger amounts of glucose have also been used, 
but it is better, on the whole, as Strauss has pointed out, to give 
glucose and not to exceed the dose of 100 grammes. 

Especially interesting are the results which have been obtained in 
various diseases of the liver, to which organ the important function 
of preventing an undue accumulation of sugar in the blood has been 
repeatedly ascribed. Bierens de Haen thus reports that of twenty- 
nine cases of various hepatic diseases he found sugar in eighteen, 
after the administration of 150 grammes of cane sugar, and v. 
Jaksch claims to have obtained positive results in 15 cases of phos- 
phorus poisoning out of 43. Strauss, on the other hand, states that 
he found sugar in only two out of his 38 cases, and has collected 107 
further cases from the literature, where sugar could only be demon- 
strated in fourteen. If we add these together we have 145 cases of 
various hepatic diseases with negative results in 88.9 per cent. Re- 
ferring to the contradictory results, which have thus been obtained, 
Strauss points out that these may have been accidental in part, but 
that the interpretation which has been offered by v. Jaksch and de 
Haen may not have been correct. It is thus possible that in his 
cases of phosphorus poisoning other factors, besides the changes in 
the liver, such as the action of the poison upon the nervous system, 
etc., have played a role, as a digestive glycosuria may also occur in 
connection with other forms of intoxication, as in fevers, following 
the administration of large doses of diuretin, in acute alcoholism, 
etc., where the liver is not the only organ that is involved. Strauss 
further shows that great care must be exercised in the selection of 
the material for such investigations, and believes that errors referable 
to this source may have been incurred by Bierens de Haen. He 
thus cites two cases of hypertrophic cirrhosis, associated with de- 
lirium tremens, in which small amounts of sugar could be demon- 
strated in the urine a few days after recovery from the delirium, 
while shortly after, negative results only could be obtained. The 
lowering effect of alcoholism upon the limit to the assimilation of 
glucose is a well-known phenomenon, and it would be erroneous to 
conclude that, because alcoholism may call forth organic changes 
in the liver, the digestive glycosuria in such eases is referable to 
such alterations. Without further entering into the question at 
this place, it appears that diseases of the liver per se do not materi- 
ally lessen the power of assimilation of glucose, and that other 
forces are at the disposal of the body to supply the glycogen-forming 
or retaining power of the liver, when this becomes insufficient, and 



404 THE URINE. 

that these also must be at fault, when a digestive glycosuria is ob- 
served in association with hepatic disorders. 

The association of digestive glycosuria with various diseases of the 
nervous system has been carefully studied by v. Jaksch, Strumpell, 
Strauss, von Oordt, Geelvink and Arndt. From the work of these 
investigators it appears that digestive glycosuria is only rarely seen 
in spinal diseases, and is decidedly more common in the functional 
diseases of the central nervous system, than in the organic affections. 
In the neuroses a positive result has thus been obtained in 42 out of 
210 cases, which I have been able to collect from the literature. 
Most frequently it is met with in the traumatic neuroses, where 
Strauss observed the phenomenon in 37.5 per cent, of his 40 cases, 
while in the non-traumatic forms only 14.4 per cent, were insuffici- 
ent in this respect. Among the organic diseases of the central nerv- 
ous system it appears that diffuse cerebral lesions, referable to 
alcohol and syphilis are more likely to give rise to this form of gly- 
cosuria than the more localized lesions. 

A digestive glycosuria is further observed in numerous febrile dis- 
eases, such as pneumonia, typhoid fever, acute articular rheumatism, 
scarlatina, tonsillitis, etc. The amount of sugar, which is usually 
found, varies from 0.5 to 3 per cent.; larger amounts may, however, 
also be encountered, and one case is on record in which 8 per cent, 
were present. 

Very common also, as I have indicated, is the digestive glycosuria 
of drinkers and there can be but little doubt that the habitual inges- 
tion of large quantities of beer and spirits will in the course of time 
lead to a more than temporary enfeeblement of the carbohydrate 
metabolism. 

Among the diseases of the skin, digestive glycosuria is notably 
associated with psoriasis, and it is interesting to note that the same 
disease is not infrequently seen in diabetic patients. Gross thus 
records 5 cases, in 4 of which the psoriasis had existed for many 
years before the appearance of diabetic symptoms. Similar in- 
stances are recorded by Strauss, Grube, Polotebuoff, Meissen, 
Schutz, a. o. 

During pregnancy digestive glycosuria is also frequently observed, 
and is by some regarded as a fairly constant symptom and one of 
diagnostic importance. The amount is quite variable, and while 
Lanz records one case in which 29.6 grammes of glucose were found, 
after the ingestion of 100 grammes, such figures are certainly un- 
common, and as a general rule less than 3 grammes are recovered 
from the urine. After confinement the power of assimilation for 
glucose no longer appears to be subnormal. 

Of other pathologic conditions in which a digestive glycosuria 
has been observed there may be mentioned : acute and chronic 



THE CHEMISTRY OF THE URINE. 405 

lead-poisoning, poisoning with nitro-benzol, anilin dyes, opium, 
atropin, carbon monoxide ; further the febrile form of embavras gas- 
trique, etc. 

In these, however, the phenomenon has received but little atten- 
tion. Very important, however, is the fact that in diabetes mellitus 
the sugar may also at times disappear from the urine, while its elim- 
ination is replaced by an excessive excretion of uric acid or phos- 
phates. In such cases a glycosuria may be produced with ease by 
the ingestion of 100 grammes of glucose, a point which may be of con- 
siderable value in diagnosis. It is also important to note that the 
exhibition of such amounts of sugar in true diabetes will cause an 
increased elimination, while this apparently does not occur in other 
forms of glycosuria. 

Interesting further is the fact that in diabetic patients an increased 
elimination of sugar can be called forth by the administration of full 
doses of copaiba. That this drug is in itself capable of lowering the 
limit to the assimilation of glucose, has recently been shown by Bett- 
mann. A digestive glycosuria was thus produced in 4 patients out 
of 12, to whom copaiba had been given, for one week, in amounts 
varying from 1-2 grammes. 

The digestive glycosuria to which reference has been made in the 
above pages, is generally spoken of as the digestive glycosuria e sac- 
char o. Similar results have been obtained after the administration 
of starches in excess, viz, 150—200 grammes. But while a digestive 
glycosuria e saccharo is only regarded as a possible indication of a 
pathologic alteration of the carbohydrate metabolism, it is gener- 
ally thought that every glycosuria ex amylo is indicative of a definite 
disturbance, in the sense of diabetes, unless special factors, such as 
an increase of the surrounding temperature, diminished irradiation of 
heat, or complete lack of muscular activity are at play. Strauss, 
however, has shown that in cases in which a somewhat more than 
temporary predisposition toward glycosuria e saccharo exists, as in 
alcoholics, for example, a coincident tendency toward glycosuria ex 
amylo may likewise be demonstrated. As a result of his experiments 
he concludes that the difference betAveen the digestive glycosuria e 
saccharo and glycosuria ex amylo is essentially a question of degree. 
Ceteris paribus it appears that harmful influences of a light character 
lead to glycosuria e saccharo, while grave insults call forth glycosuria 
ex amylo. It results practical ly, that the prognosis in those eases, in 
which digestive glycosuria follows a temporary insult is far better, 
than when the carbohydrate metabolism is permanently damaged, 
and especially when a glycosuria ex amylo accompanies a glycosuria 
e saccharo. In the first instance it is scarcely likely that true dia- 
betes will develop in the course of time, while in the latter this is at 
least possible. 



406 THE URINE. 

Aside from the digestive form of glycosuria, which has just been 
considered, and which is produced artificially, an idiopathic transitory 
form is also known to occur. A transitory glycosuria, apparently of 
central origin, is thus noted in connection with lesions affecting the 
central as well as the peripheral nervous system, such as tumors and 
hemorrhages at the base of the brain, lesions of the floor of the fourth 
ventricle, cerebral aud spinal meningitis, concussion of the brain, 
fracture of the cervical vertebra?, tetanus, sciatica ; following epilep- 
tic, hystero-epileptic, and apoplectic seizures, mental shock produced 
by railroad accidents (traumatic neuroses), etc., mental strain and 
worry, fatigue, and anxiety. Glycosuria following epileptic and 
apoplectic attacks, however, does not appear to be so common as 
is generally believed. v. Jaksch was unable to demonstrate the 
presence of sugar in 50 recent cases of hemiplegia, and I have only 
reached negative results in a large number of cases of epilepsy, with 
urines voided within the first few hours following the seizure. 

Siegmund noted a transitory glycosuria in 52.38 per cent, of 
general paretics, in 7.4 per cent, of epileptics, and in 3.77 per cent, 
of dementia cases, while it was not observed in any other mental 
diseases. 

It is a well-known fact that Claude Bernard experimentally pro- 
duced a transitory glycosuria by puncturing a certain spot in the 
floor of the fourth ventricle, the supposed origin of the hepatic 
vasomotor nerves, and it is not improbable that this neurotic form 
of glycosuria is due to some direct or reflex influence affecting that 
portion of the medulla. 

The transitory glycosuria which is occasionally observed, particu- 
larly during convalescence, in acute febrile diseases, such as typhoid 
fever, scarlatina, measles, cholera, diphtheria, influenza, and especially 
malaria, may possibly be referable to the action of ptomams or 
leukoma'ins upon this centre. Seegen reports five cases of malaria 
with " diabetes " in which both conditions disappeared under the ad- 
ministration of quinine. In diphtheria glycosuria appears to be of 
common occurrence. Binet thus obtained a positive result in 29 
cases out of 70 ; 27 times in severe infections out of 38, and twice 
in mild cases out of 32. I have personally found a transitory gly- 
cosuria in 4 cases out of 32 ; the infection in these was of moderate 
severity. Hibbard and Morrissey arrived at similar results. 

A glycosuria of toxic origin has been noted in cases of poisoning 
with curare, chloral hydrate, sulphuric acid, arsenic, alcohol, carbon 
monoxide, morphin, etc., and even after simple transfusion of nor- 
mal salt-solution into the blood. Phloridzin, a glucoside obtained 
from the bark of the root of the apple tree, will likewise cause sugar 
to appear in the urine. The glycosuria thus produced is, however, 
only temporary and ceases with the withdrawal of the drug. 



THE CHEMISTRY OF THE URINE. 407 

The occurrence of a transitory glycosuria under the conditions 
above mentioned, and which may be met with in almost any disease, 
moreover, Avhile interesting from a theoretical standpoint, must, in 
the majority of instances, be regarded as a medical curiosity only, 
and it is but rarely possible to draw either diagnostic, prognostic, or 
therapeutic conclusions from its existence. 

A persistent form of glycosuria is noted in connection with certain 
lesions of the brain, especially those affecting the floor of the fourth 
ventricle, and is at times of considerable value in diagnosis. 

A continuous elimination of sugar is noted principally in the com- 
plex of symptoms to which the term diabetes mellitus has been applied, 
and it is this condition to which the greatest practical and theoretical 
interest attaches. 

Diabetes mellitus is essentially a persistent form of glycosuria, as- 
sociated with the occurrence of a more or less intense polyuria and a 
greatly increased elimination of all the metabolic products normally 
found in the urine, with the exception of uric acid, which is usually 
present in diminished amount. In the more advanced cases aceto- 
nuria, lipuria, and lipaciduria may also exist. Diabetes, however, is 
not a persistent form of glycosuria in an absolute sense of the word, 
as times may occur, in the course of the disease, when glucose is tem- 
porarily absent. 

The quantity of sugar excreted may be enormous, and 180 to 360 
grammes pro die may be quite frequently observed ; but, as stated 
above, this quantity may diminish to zero under various conditions, 
such as the occurrence of intercurrent diseases, but often also with- 
out any apparent cause, and not infrequently in the condition which 
has been termed diabetic coma. Some cases are also observed in 
which, from beginning to end, mere traces are eliminated, the total 
amount of sugar not exceeding a few grammes, while the course 
of the disease rapidly tends toward a fatal termination, so that the 
severity of the pathologic process cannot be measured by the ((mount of 
sugar eliminated. A few years ago I had occasion to observe a dia- 
betic patient in whom, for months, a daily examination of the urine 
never revealed the presence of more than 5 to 10 grammes of sugar, 
and where death occurred after eighteen months. 

At the same time it should be remembered that diabetes cannot 
be excluded by one or even more negative urinary examinations, and 
the value of repeating such examinations three or four hours after 
the exhibition of 100 grammes of glucose, as indicated, cannot be too 
strongly insisted upon. 

Clinicians are in the habit of determining the severity of a case, to 
a certain extent at least, by the condition of the urine under a diet 
free from starches and sugars, and generally regard those cases as the 
more serious, in which the glycosuria does not disappear under a diet 



408 THE URINE. 

of this character, while a more favorable prognosis is given if the 
sugar disappears. It should be remembered, however, that there 
are numerous exceptions to this rule, and that a light case, — i. e., 
one in which the sugar has disappeared under appropriate dietetic 
treatment, — may suddenly exhibit symptoms, seen only in the most 
severe forms, and succumb to one of the numerous intercurrent ma- 
ladies, while apparently severe cases may suddenly assume the more 
benign type. 

It may not be out of place in this connection to say a few words 
regarding the specific gravity of the urine. While usually very 
high, varying between 1.030 and 1.060, as pointed out in the chap- 
ter on Specific Gravity, comparatively Ioav figures are noted at times, 
such as 1.012, corresponding to a quantity of urine not exceeding 
1,000 c.c, and implying, of course, a greatly diminished elimination 
of solids. This is especially marked in those cases described by 
Hirschfeld, in which, as pointed out in the chapter on Urea, the re- 
sorption of nitrogenous material from the digestive tract is below par. 
Polyuria, a fairly constant symptom of the more common types of 
diabetes mellitus, is much less pronounced in Hirschfeld's form, and 
may be altogether absent, although it is true that this may occur in 
ordinary diabetes also. 

The simultaneous occurrence of glycosuria, acetonuria, lipuria, 
and lipaciduria (which see) is probably always indicative of true 
diabetes. 

It is, of course, impossible to enter here into a detailed considera- 
tion of the origin of diabetes. Suffice it to say that a persistent 
glycosuria, aside from nervous influences, may be referable, on the 
one hand, to an inability on the part of the liver to transform into 
glycogen all of the sugar which is carried to this organ, or, on the 
other hand, to an inability on the part of the muscular system of the 
body to utilize all the sugar sent to it by the liver, which may have 
performed its work properly. Accordingly, we may distinguish 
between a hepatogenic and a myogenic diabetes. As a matter of fact, 
cases are seen, usually belonging to the milder form of the disease, in 
which the sugar may be temporarily caused to disappear from the 
urine by muscular exercise. On the other hand, again, cases are 
seen, and unfortunately only too frequently, in which, notwithstand- 
ing a total abstinence from carbohydrates and a free indulgence in 
muscular exercise, the sugar does not disappear from the urine. In 
such cases it is permissible to speak of a hepatogenic combined with 
a myogenic diabetes. 

Within recent years it has been shown that pancreatic disease is 
frequently associated with diabetes, and while the number of cases 
in which no pancreatic lesions are discovered is still too large to war- 
rant the conclusion that disease of this organ is invariably associated 



THE CHEMISTRY OF THE URINE. 409 

with glycosuria, it must still be admitted that lesions of the pancreas 
are the more frequently met with in diabetes the more closely the 
organ is examined. It appears to be certain that diabetes may be 
produced by pancreatic disease. As to the manner, however, in 
which such a result can occur we are as yet in profound ignorance. 

Hirschfeld pointed out the fact that, while in the majority of 
diabetic patients the proteid food ingested is quite satisfactorily uti- 
lized, the assimilation of albumins and fats is very much below par 
in others, and particularly so in cases of diabetes associated with 
pancreatic disease. (See also Urea.) Observations in this direction 
are as yet very scanty, so that a definite opinion cannot be expressed 
regarding the utility in diagnosis of investigations similar to those of 
Hirschfeld. I have had occasion to observe a diabetic patient for 
some length of time, in whom, notwithstanding that conclusions were 
reached similar to those of Hirschfeld, the existence of pancreatic 
disease could not be determined post mortem. 

Whether or not a renal and a thyroigenic diabetes also exists, as 
has recently been suggested, must still remain an open question. 

Tests for Sugar. — The tests for sugar usually employed in the 
clinical laboratory depend upon the following properties of sugar : 

1. It acts as a reducing agent upon certain metallic oxides, such 
as copper and bismuth, in the presence of alkalies (Fehling's, Trom- 
mer's, Bottger's, and Ny lander's tests). 

2. In the presence of yeast (saccharomyces cerevisise) it under- 
goes fermentation, with the formation of alcohol, carbonic acid, 
succinic acid, glycerin, and a number of other bodies, such as amyl 
alcohol, etc. (fermentation test). 

3. With phenylhydrazin sugar forms an insoluble crystalline com- 
pound — phenylglucosazon. 

4. Solutions of glucose turn the plane of polarized light to the 
right, from which property glucose has also received the name 
dextrose. 

In every case the urine should first be tested for the presence of 
albumin, which should be removed by boiling. 

Trommer's Test. — A few c.c. of urine are strongly alkalinized 
with sodium hydrate solution, and treated with a 5-per-cent. solution 
of sulphate of copper, added drop by drop, until the cupric oxide 
formed is no longer dissolved. The mixture is carefully heated, 
when in the presence of sugar a yellow precipitate of cuprous hy- 
droxide is formed, which will gradually settle to the bottom as a red 
sediment of cuprous oxide. 

It is important to note that while sugar, unless present in mere 
traces, can readily be detected in this manner, other substances arc 
or may be present in the urine, such as uric acid, kreatin and krea- 
tinin, allantoin, nucleo-albumin, milk-sugar, pyrocatechin, hydro- 



410 THE URINE. 

chinon, and bile-pigment, which may likewise reduce cupric oxide. 
Following the ingestion of benzoic acid, salicylic acid, glycerin, 
chloral, sulphonal, etc., reducing substances also appear. These may 
be generally disregarded, it is true, if care is taken not to boil the 
urine after the addition of the copper sulphate, as the precipitation of 
cuprous oxide in the presence of sugar takes place before this point 
is reached. Unfortunately, however, the test, when thus applied, 
yields negative results, or results which are doubtful if traces only 
are present, so that it cannot be utilized, as a rule, in the study of 
transitory or digestive glycosuria. 

Fehli^g's Test. — This is a modification of the test just described, 
and can be recommended only with the same restrictions. 

Two solutions are employed, which must be kept in separate 
bottles, the one containing 34.64 grammes of crystallized copper sul- 
phate, dissolved in 500 c.c. of distilled water, and the other 173 
grammes of the tartrate of potassium and sodium and 125 grammes 
of potassium hydrate, dissolved in an equal volume of water. Equal 
parts of the two solutions, mixed in a test-tube and diluted with 
four times as much water, are boiled, when a small amount of urine is 
added. In the presence of sugar a precipitate of the yellow hy- 
droxide of copper or of red cuprous oxide will be produced ; but care 
should be taken only to warm, and not to boil the solution after the addi- 
tion of the urine. 

Not infrequently it will be observed that, upon standing, when no 
precipitation has occurred previously, the blue color of the mixture 
changes to an emerald-green, while the solution at the same time be- 
comes turbid. Such a phenomenon should not be referred to the 
presence of sugar, as it is in all probability due to the action of other 
reducing substances, such as those mentioned above. 

Bbttger's test with Nylander's modification. — A few c.c. of urine are 
treated in the proportion of 11 : 1 with Almen's solution. This is 
prepared by dissolving 4 grammes of tartrate of potassium and so- 
dium, 2 grammes of subnitrate of bismuth, and 10 grammes of sodium 
hydrate in 90 c.c. of water, heating the solution to the boiling-point 
and filtering upon cooling, when it should be kept in a colored-glass 
bottle. The mixture of urine and AkueVs fluid is thoroughly boiled, 
when in the presence of sugar a grayish, dark-brown, and finally a 
black precipitate, consisting of bismuthous oxide or of metallic bis- 
muth, is obtained. Albumin, if present, must first be removed, as, 
owing to the sulphur contained in the albuminous molecule, alkaline 
sulphides could be formed upon boiling, and acting upon the bismuth 
would give rise to the formation of black sulphide of bismuth, which 
may be mistaken for metallic bismuth. Rhubarb-pigment, as well 
as melanin and melanogen (which see), and free sulphuretted hydrogen 
must also be absent, as misleading results will otherwise be obtained. 



THE CHEMISTRY OF THE URINE. 



411 



Ny lander's test, as that of Trommer and Fehling, is, however, 
also not without objections, as a partial redaction of the subnitrate 
of bismuth may be produced by other substances, such as kairin, 
tincture of eucalyptus, turpentine, and large doses of quinine. 

Fermentation-test. — -A small piece of ordinary compressed 
yeast is shaken with some of the suspected urine and a test-tube filled 
with the mixture, to which some mercury is added. The tube is 
then inverted into a vessel containing mercury, and allowed to stand 
in a warm place (22 °-28° C). If sugar is present, fermentation 
will occur in the course of twelve hours, and the carbon dioxide 
formed rise to the top of the tube, gradually displacing more and 
more of the urine or mercury, as the amount of the gas increases. 
It is easy to demonstrate that the gas thus formed is actually carbon 
dioxide, by introducing a small piece of caustic soda into the urine, 
when, owing to absorption of the carbon dioxide, the liquid will 
again rise in the tube. Very convenient for this purpose also are 
the saccharimetric tubes of Einhorn (Fig. 97) or Lohnstein (Fig. 

Fig. 97. 







Einhorn's saochariniotor. 



99), which are employed as just described, a little mercury being 
poured into the bent limb to guard against an escape o^ gas. As the 
yeast itself, however, may give rise to the formation of a little gas, in 
the absence of sugar, it will always be well to make a control-test 



412 THE URINE. 

with normal urine ; i. e., to prepare a similar tube with normal urine 
mixed with yeast, and to allow this to stand at the same temperature. 
If a positive result is thus obtained, there can be no doubt as to the 
presence of a fermentable substance in the urine. This, however, 
is not necessarily glucose, as other carbohydrates, such as lactose, 
maltose, and levulose, may likewise undergo fermentation. Still, if 
large amounts of gas are obtained, and if Trommer's test also yields 
a positive result, it will be fairly safe to regard the substance present 
as glucose. 

Phexylhydeazix Test. — As originally proposed by v. Jaksch 
the test is conducted as follows : Six to eight c.c. of urine are treated 
with two pinches of phenylhydrazin hydrochlorate (0.4-0.5 gramme) 
and 3 parts of acetate of sodium (1 gramme), and warmed until the 
salts have been dissolved, a little water being added if necessary. 
The tube is placed in boiling water for twenty to thirty minutes, and 
then transferred to a beaker, filled with cold water. If sugar is 
present in moderate amounts, a bright yellow crystalline deposit will 
at once be thrown down, and partly adhere to the sides of the tube. 
But even in the presence of mere traces a careful microscopic exami- 
nation will reveal the presence of crystals of phenylglucosazon (Plate 
XV.). These are seen singly or arranged in bundles and sheaves, 
composed of very delicate bright-yellow needles which are insoluble 
in water. 

Still more convenient is the following modification of the test, as 
suggested by Kowarsky. Five drops of pure phenylhydrazin are 
mixed, in a test-tube, with ten drops of glacial acetic acid, and one 
c.c. of a saturated solution of common salt. A white, caseous mass 
results, which consists of phenylhydrazin hydrochlorate and sodium 
acetate. To this, 3 c.c. of urine are added, when the mixture is 
boiled for two minutes, and then set aside to cool. Should more than 
0.5 per cent, of sugar be present the typical crystals begin to sepa- 
rate out after two minutes already, and may be recognized with the 
naked eye. In the presence of smaller amounts, the mixture should 
be allowed to stand for from 15 to 20 minutes, or if traces only are 
present, for one hour. 

This test, properly applied, is undoubtedly not only the most deli- 
cate, but at the same time the most reliable, as no other substances 
which may be present in the urine, excepting maltose and certain 
pentoses, will give rise to the formation of anosazon. Hence, when- 
ever any doubt is felt as to the nature of a substance reacting in a 
positive manner with the reagents described above, recourse should 
be had to this test. It has been stated that maltose forms an excep- 
tion ; this, hoAvever, will never become embarrassing, as the micro- 
scopic appearance of the maltosazon crystals differs from that of the 
phenylglucosazon. The melting-point of phenylglucosazon, 205° 



PLATE XV. 




Phenyl-Glueosazon Crystals obtained from a Diabetic Urine. 



THE CHEMISTRY OF THE URINE. 413 

C, moreover, is about 15° higher than that of the maltosazon — 
190°— 191° C. To determine this point it is necessary to filter 
off the osazon, and, after washing with water, to dissolve it upon a 
filter by means of a little hot alcohol. From this alcoholic solution 
it is reprecipitated by water, when it may be collected and dried over 
sulphuric acid. The melting-point is then determined according to 
the usual methods. 

• The pentosazons can be readily distinguished from glucosazon by 
their melting-points (which see). 

The amount of lactose which may be found in the urine, is far too 
small to give rise to the formation of an osazon, when the test is di- 
rectly applied to the urine. 

With the conjugate glycuronates, as such, phenyl-hydrazin does 
not form any compounds (see Glycuronic acid). 

Polarimetric Test. — Glucose turns the plane of polarized light 
to the right, but the same may be said of maltose, the degree of polar- 
ization of which is even more intense, so that it may be impossible 
to state in a given case, whether such rotation is referable to a large 
quantity of glucose or to a smaller quantity of maltose. The latter 
substance, however, occurs in the urine but rarely, and may be recog- 
nized not only by the microscopic appearance of its osazon, but also 
by the fact that its power of reduction is increased in the presence of 
sulphuric acid and by the application of heat. 

An error which may further arise with the employment of the 
polarimetric method is referable to the fact that, if glucose is 
present in only small amounts, while the urine contains large quan- 
tities of /9-oxybutyric acid, the latter turning the plane of polarized 
light to the left, it may happen that the rotation in this direction 
will neutralize or even overcome any rotation to the right which may 
be due to glucose. In such cases, however, the urine will react in a 
positive maimer with the other reagents described, and the fermented 
urine will, moreover, turn the plane of polarization still more strongly 
to the left, indicating the presence of a dextro-rotatory substance, and 
in all probability of glucose. 

The delicacy of this method varies with the instrument employed ; 
the figures given below were obtained with the apparatus of Lippich, 
which yields the best results. 

(For a description of this method see the Quantitative Estimation 
of Sugar by Means of the Polarimeter.) 

Table showing the Delicacy of the Tests Des 

Trommer's test . 

Folding's test . 

Nylander's test .... 

Fermentation-test .... 

Phenylhydrazin test 

Polarimetric test .... 



a Tests De 


SCRIBED. 


0.0026 pei 


r cent. 


0.0008 


" 


0.025 


a 


o.i -0.05 


a 


0.025-0.05 


tt 


0.025-0.05 


a 



414 



THE URINE. 



Table Showing the Behavior of the Various Forms of Sugar, which 
May Occur in the Urine, toward the Tests Described. 



Trommer's, viz, 
Fehling's Test. 



Nvlander' 
test. 



Fermenta- 
tion-test. 



Phenvlhvdrazin 
test, 



Polarirnetric 
test. 



Glucose. 



Positive reaction. Positive 

reaction. 



Positive Positive reaction ; . Potation toward 
reaction. Melting-point the right. 

, 205° C. 



Levulose. Positive reaction. Positive 
reaction. 



Maltose. 



Lactose. 



Laiose. 



Positive reaction. Positive 
reaction. 



Positive reaction. Positive 
i reaction. 



Positive reaction 
on boiling only ; 
1.2-1.8 per cent, 
more is obtain- 
ed than by the 
polarimeter. 



Positive 
reaction. 



Positive 
reaction. 



Positive 
reaction. 



No re- 
action or 
only a 
very faint 
one. 



No reac- 
tion. 



Same osazon ob- 
tained as with 
glucose, only 
more rapidly. 

A maltosazon is 
formed: melting- 
point 190-191° C. 

No reaction in the 
concentration in 
"which it may oc- 
cur in the urine ; 
melting-point 
200° C. 

With phenylhy- 
drazin a yellow- 
ish-brown, non- 
crystallizable oil 
is obtained. 



Rotation toward 
the left. 



Rotation toward 
the right. 



Rotation toward 
the right; in- 
creased by boil- 
ing with a2.5-p.- 
c. solution of sul- 
phuric acid. 

No reaction, or ro- 
t a t i o n toward 
the left. 



Clinically, it is unimportant to search for minute traces of sugar, 
such as may be found in every normal urine, and the reader is re- 
ferred to special works on physiologic chemistry for a consideration 
of the methods generally employed (See method of Baumann and v. 
Udranszky, p. 459). 

Quantitative Estimation of Sugar. — The methods used in the 
quantitative estimation of sugar are essentially based upon the quali- 
tative tests described. 

Fehling's Method. — Fehling's solution, prepared as described 
above, is of such strength that the copper, contained in 10 c.c, is 
completely reduced by 0.05 gramme of glucose. If then urine is 
carefully added to this quantity until complete reduction takes place, 
the amount of sugar contained in a given specimen of urine can be 
readily calculated according to the following equation : 

y : 0.05 : : 100 : x, and x = -, 

in which y indicates the number of c.c. of urine required to reduce 
the 10 c.c. of Fehling's solution, and x the amount of sugar con- 
tained in 100 c.c. of urine. 

As the best results arc only obtained if from 5 to 10 c.c. of urine 
are used in one titration, it is usually necessary to dilute the urine 
to the required degree ; in the determination of this point the specific 
gravity may serve as a guide. As a general rule, urines of a specific 
gravity of 1.030 should be diluted five times, and if the density is 
still higher, ten times. To be certain that the proper degree of 



THE CHEMISTRY OF THE UBTNE. 



415 



dilution has been reached, 5 c.c. of Fehling's solution are treated with 
1 c.c. of the diluted urine, a little caustic soda solution and distilled 
water being added to make in all about 25 c.c. This mixture is 
thoroughly boiled ; if the fluid still remains blue another 1 c.c. of 
diluted urine is added, and so on, until the last two tests differ by 
1 c.c. of urine, the last c.c. added causing a separation of cuprous 
oxide. In this manner the percentage of sugar may be approxi- 
mately determined. Albumin, if present, must first be removed by 
boiling. 

Ten c.c. of Fehling's solution, diluted with 40 c.c. of water, are 
placed in a porcelain dish and boiled. While boiling, the diluted 
urine is added from a burette, 0.5 c.c. at a time, when, as a rule, the 
precipitated cuprous oxide will rapidly settle, so that gradually a 
white bottom may be seen through the blue field, the color of which 
becomes less and less intense upon the further addition of urine 
until, finally, the solution is almost colorless. When this point is 
reached the urine is added only drop by drop, until the decoloriza- 
tion is complete. The degree of dilution multiplied by 5 and the 
result divided by the number of c.c. of diluted urine employed will 
then indicate the percentage-amount of sugar. In the following table 
the percentage results corresponding to the number of c.c. of undi- 
luted urine employed will be found : 



Sugar. — Quantity of Glucose pro litre, corresponding to the number of cubic centimetres 
used for the complete reduction of 10 cubic centimetres of Fehling' s solution. 





1 


Vio 


7io 


8 /io 


Vio 


5 /io 


Vio 


Vio 


Vio 


Vio 


1 


50.00 


45.44 


41.68 


- 38.46 


35.70 


33.32 


31.24 


29.40 


27.76 


26.30 


2 


25.00 


23.80 


22.72 


21.72 


20.84 


20.00 


19.22 


18.50 


17.84 


17.21 


3 


16.66 


16.00 


15.62 


15.14 


14.15 


14.28 


13.88 


13.50 


13.14 


12.82 


4 


12.50 


12.18 


11.90 


11.62 


11.36 


11.10 


10.86 


10.62 


10.40 


10.20 


5 


10.00 


9.80 


9.60 


9.42 


9.24 


9.08 


8.92 


8.76 


8.62 


8.50 


6 


8.32 


8.18 


8.06 


7.92. 


7.80 


7.68 


7.56 


7.44 


7.34 


7.24 


7 


7.14 


7.04 


6.94 


6.86 


6.78 


6.66 


6.56 


6.48 


6.40 


6.32 


8 


6.24 


6.16 


6.08 


6.02 


5.94 


5.88 


5.80 


5.74 


5.68 


5.60 


9 


5.54 


5.48 


5.42 


5.36 


5.30 


5.24 


5.20 


5.16 


5.12 


5.06 


10 


5.00 


4.94 


4.90 


4.82 


4.78 


4.76 


4.70 


4.66 


4.62 


4.58 


11 


4.54 


4.50 


4.46 


4.42 


4.38 


4.34 


4.30 


4.26 


4.22 


4.20 


12 


4.16 


4.14 


4.12 


4.08 


4.04 


4.00 


3.98 


3.96 


3.02 


3.86 


13 


3.84 


3.80 


3.78 


3.76 


3.74 


3.70 


3.68 


3.66 


3.62 


3.58 


14 


3.56 


3.54 


3.52 


3.48 


3.46 


3. 1 1 


3.42 


3.40 


3.36 


3.34 


15 


3.32 


3.32 


3.28 


3.26 


3.24 


3.22 


3.20 


3.18 


3.16 


3.14 


16 


3.12 


3.10 


3.08 


3.04 


3.04 


3.02 


3.00 


2. OS 


2.06 


2.01 


17 


2.94 


2.92 


2.90 


2.8S 


2.86 


2.84 


2.S2 


2.S2 


2.80 


2.7S 


18 


2.76 


2.76 


2.74 


2.72 


2.70 


2.70 


2. US 


2.61 


2.61 


2.61 


19 


2.62 


2.62 


2.60 


2.60 


2.58 


2.56 


2.56 


2.54 


2.52 


2.52 


20 


2.50 


2.50 


2.48 


2.48 


2.44 


2. 12 


2. 12 


2. 10 


2. JO 


2.38 


21 


2.38 


2.36 


2.34 


2.34 


2.32 


2.32 


2.30 


2.30 


2.28 




22 


2.26 


2.26 


'2:2 [ 


2.21 


.) .>•_) 


.) ■>•> 


2.20 


2.20 


2. IS 


2. 18 


23 


2. 16 


2.16 


2.14 


2.14 


2.12 


2 '.12 


2.12 


2.10 


2.10 


2.10 


24 


2.08 


2.08 


2.06 


2. 06 


2.0H 


2.0 1 


2.01 


2.02 


2.02 


2.02 


25 


2.00 


1.98 • 


l.'.IS 


1.96 


1.96 


1.96 


1.94 


1.01 


1 .92 


1.92 


26 


1.92 


1 .92 


1.90 


1 .90 


l.SS 


l.SS 


l.SS 


1.S6 


L.86 


L.86 


27 


LSI 


1.S2 


1.82 


1 .82 


1.82 


1.S0 


1.S0 


1.S0 


1.S0 


1.80 


28 


1.7S 


1.76 


1.71 


1.71 


1.71 


1.71 


1.71 


1.71 


1.71 




29 


1.7'J 


1.70 


1.70 


1.70 


1.70 


L.68 


1.68 


1.68 


1.68 


1.66 


30 


1.66 


1.66 


1.65 


1.61 


1.63 


l.i>2 


1.62 


1.62 


1.62 


1.62 



416 THE URINE. 

Unfortunately, it is difficult, as a general rule, to determine the 
point exactly, when all the copper has been reduced ; i. e. } the point 
at which the blue color has entirely disappeared. When it is thought 
that this has been reached, about 1 c.c. should be filtered through 
thick Swedish filter-paper, and the filtrate, which must be absolutely 
clear, acidified with acetic acid and treated with a drop or two of a 
solution of potassium ferrocyanide. If unreduced copper is still 
present in the solution, a brown color will result, indicating that 
sufficient urine has not been added. But if, on the other hand, no 
brown discoloration is noted, it is possible that the desired point has 
already been passed, when the titration should be repeated. At 
times the precipitate will not settle at all, and even pass through the 
filter, so that it is practically impossible to determine the end of the 
reaction. In such cases the following procedure, suggested by Cause, 
will be found of value : 

Ten c.c. of Fehling's solution are diluted with 20 c.c. of distilled 
water and treated with 4 c.c. of a -^-per-cent. solution of potassium 
ferrocyanide. While boiling, the diluted urine is now added drop 
by drop, until the blue color has entirely disappeared. A precipitate 
does not appear at all with this method. 

In order to obtain reliable results, however, the Fehling's solution 
must be prepared with great care and its strength determined. This 
may be done in the following manner : 0.2375 gramme of pure 
crystallized cane-sugar, dried at 100° C, is dissolved in 40 c.c. of 
distilled water, to which 22 drops of a -^-per-cent. solution of sul- 
phuric acid have been added. This solution is kept on the boiling 
water-bath for an hour, when it is allowed to cool and diluted to 
100 c.c. with distilled water. Twenty c.c. of this solution will then 
contain exactly 0.05 gramme of glucose, corresponding to 10 c.c. of 
Fehling's solution, if this is of the required strength. If too strong, 
so that 21 c.c. of the sugar solution, for example, are required to 
obtain a complete reduction of the copper, the strength of Fehling's 
solution may be determined according to the equation : 20 : 0.05 : : 
21 : x, and x = 0.0525. If too weak, on the other hand, so that 
19 c.c, for example, are required, its strength is similarly deter- 
mined : 20 : 0.05 : : 19 : x, and x = 0.0475. 

The following method, suggested by Knapp, is said to be better 
than that of Fehling, as daylight is not necessary, as it is applicable 
even in cases in which the amount of sugar is small, as the solution 
keeps for a long while, and as it is simpler. 

The principle of the method depends upon the observation that 
the cyanide of mercury in alkaline solutions is reduced to metallic 
mercury in the presence of sugar. The solution which is required 
should contain 1 grammes of chemically pure, dry cyanide of mer- 
cury and 100 c.c. of a solution of sodium hydrate (sp. gr. 1.145) to 



THE CHEMISTRY OF THE URINE. 417 

the litre. Twenty c.c. of this solution correspond to 0.05 gramme 
of glucose. 

Knapp's Method. — Twenty c.c. of the solution are placed in a 
small retort and diluted with 80 c.c. of water. If we have reason 
to suppose that the urine contains less than 0.5 per cent, of sugar, 
40 to 60 c.c. are sufficient. The solution is then heated to the boil- 
ing-point, when the diluted urine (see below) is added, at first 2 c.c. 
at a time, then 1 c.c, 0.5 c.c, 0.2 c.c, and 0.1 c.c, as the final 
point is approached. After every addition the solution is boiled for 
one-half minute. As the end-reaction is approached the solution 
begins to become clear, and the mercury, together with the phos- 
phates, settles to the bottom. The final point is determined by plac- 
ing a drop of the supernatant fluid upon a piece of clean, white 
Swedish filter-paper, and holding this first over a bottle containing 
concentrated hydrochloric acid and then over one containing a satu- 
rated solution of sulphuretted hydrogen. If all the cyanide of mer- 
cury has not been reduced, a yellow spot will result, the color of 
which becomes the more manifest, if it is compared with one which 
has not been exposed to the action of the sulphuretted hydrogen. As 
soon as the mercury has been entirely reduced, the reading is taken. 

Example : Supposing that 15 c.c. of urine have been required, the 
corresponding amount of sugar is then found according to the fol- 
lowing equation, 20 c.c. of Knapp's solution requiring 0.05 gramme 
of sugar for its reduction : 

15 : 0.05 : : 100 x ; 15 x = 5, and x = 0.333 per cent. 

Precautions : — 1. Albumin must first be removed. 

2. The urine should not contain more than 0.5 to 1 per cent, of 
sugar. The urine is hence diluted, if necessary, as with Fehling's 
method. 

Differential Density Method. — This method is very useful 
in clinical work, and should be preferred to the more uncertain titra- 
tion with Fehling's solution, unless considerable experience has been 
acquired with the method. 

The specific gravity of the urine is accurately ascertained by 
means of a pyknometer, or a hydrometer graduated to the fourth 
decimal and provided with a thermometer indicating tenths of a 
degree. The temperature at which the specific gravity is taken 
should be that for which the hydrometer has been constructed, the 
urine being heated or cooled to the desired degree. 100 to 200 c.c. 
are then set aside in a flask, after the addition of some yeast, which 
has been washed free from mineral material, loosely stoppered or 
provided with an arrangement like the one shown in the accompany- 
ing figure (Fig. 98). After twenty-four hours, it' but little sugar is 
present, or forty-eight hours, if there is much, the specific gravity is 
27 



418 



THE URINE. 



again determined under the precautions given, after having filtered 
the urine. The difference in the specific gravity is then multiplied 
by 230, an empirical factor which has been found by dividing the 
amount of sugar ascertained by titration or polarization with the 
difference in the density of the urine after fermentation. The result 
indicates the percentage of sugar. The process may be hastened, 
if to every 100 c.c. of urine, 2 grammes of tartrate of potassium 
and sodium and 2 grammes of diacid-sodium phosphate are added, 
with 10 grammes of t compressed yeast, and the mixture is allowed 
to stand at a temperature of from 30° to 34° C. If but little sugar 
is present, two to three hours will be sufficient. 

That portion of the urine, in which the specific gravity is deter- 
mined before fermentation, should really be treated in the same man- 
ner. It will suffice, however, to add 0.022 to the specific gravity 
found, to make up for the increase that would otherwise be observed 
in the second specimen, owing to the addition of the salts. 

In every case the urine must be perfectly fresh, as fermentation 
generally begins spontaneously, even after standing a short time. 

Eixhorx's Method. — This will answer very well for ordinary 
purposes. Two especially constructed and graduated saccharimetric 
tubes (Fig. 97) are used, one of which is filled 
with a mixture of the suspected urine and 
yeast, and the other with normal urine and 
yeast, as a control. The tubes are then set 
aside at a temperature of from 30° to 34° C, 
when the percentage-amount of sugar in the 
urine is read off from the column of the car- 
bon dioxide formed. Should the second tube 
also show a small amount of gas, the figure 
corresponding to this amount is deducted from 
the first. 

Lohxsteix's Method. — A very conveni- 
ent modification of Einhorn's instrument, and 
one furnishing more accurate results, has been 
introduced of late by Lolmstein. As will 
be seen from the accompanying figure (Fig. 
99) this is essentially a [J -tube, open at both 
ends. The longer limb is closed during the 
process of fermentation by a ground-glass 
stopper. This stopper is provided with an air-hole to which a 
similar hole corresponds in the drawn-out portion of the tube. The 
apparatus is filled with the urine to be examined, through the bulb 
" A," while the two air-holes are communicating with each other. 
Care should be had that the liquid stands exactly at the mark 0. 
The stopper is then turned so that all communication between the 




Flask for the approximate es- 
timation of sugar by fermenta- 
tion, (v. Jaksch.) 



THE CHEMISTRY OF THE URINE. 



419 



Fig. 99. 



air and the urine is cut off. A little mercury is finally poured into 
the saccharimeter, when the instrument is placed in a vessel con- 
taining water of 35°-40° C, and main- 
tained at a temperature of about 30° C. 
After twelve hours the percentage of sugar 
is read off directly. 

Precautions : 1. As every urine contains 
traces of free carbon dioxide, it is well to 
remove this by boiling, if we have reason 
to suppose that only a small amount of 
sugar is present. Before adding the yeast, 
it is of course cooled again to the surround- 
ing temperature. 

2. As the instrument only yields satis- 
factory results, if the urine contains less 
than 1.0 per cent, of sugar, it is necessary 
to dilute it with water, when more is 
present. The specific gravity may here 
serve as an index ; urines of a sp. gr. up 
to 1.018 are examined directly; from 
1.018-1.022 they are diluted twice, from 
1.022-1.028 five times, and those above 
1.028 ten times. 

3. A test-tube, provided with the neces- 
sary marks for diluting the urine, accom- 
panies the instrument. In every case a 
small globule of yeast, approximately 6-8 mm. in diameter is added 
to the urine and shaken in the tube, until an even suspension has 
been reached. 1 

Polaeimetric Method. — For this purpose the saccharimeter of 
Soleil-Ventzke is very convenient (Fig. 100). This consists essen- 
tially of a NicoPs prism, a, which may be rotated about the axis of 
the apparatus ; a second Nicol's prism at d ; vertically placed com- 
pensating prisms, consisting of dextro-rotatory quartz at e, which 
may be moved horizontally by means of a rack-and-pinion adjust- 
ment, turned by a milled head at k, so that light can pass through 
a thicker or thinner layer of the dextro-rotatory quartz. At / 
there is a plate of gyro-rotatory quartz cut perpendicularly to the 
optical axis, and covering the entire field of vision ; at h bi quartz 
plates of Soleil, and at i an Iceland-spar crystal; be represents a 
small telescope, by means of which the biquartz plates can be ac- 
curately focused. When the compensation-prisms of this apparatus 
are in a certain position, the gyro-rotation of the plate / will be ex- 

1 Lolmstein's saccharimeter may bo procured from K. Kallmeyer <& Co., Oranien- 
burger Str. 4"), Berlin. 




Lohnsteiu 



420 



THE URINE. 



actly compensated, and the two halves of the field of vision present 
the same color, while the zero of the scale x will coincide with the 
zero of the vernier y, arranged on the upper surface of the compen- 
sators. Any change in this j>osition, produced by turning the screw 
h will cause the appearance of a different color in each half of the 

Fig. 100. 




Soleil-Veutzke' s saccharimeter. 



field of vision. If now, with a zero-position, an optically active 
dextro- or gyro-rotatory substance is interposed, the color of each 
half of the field of vision will become altered, but may be equalized 
again by changing the position of the compensators, the degree of 
change necessary to produce this result constituting an index of the 
power of rotation of the solution interposed in the tube m. 

Soleil-Ventzke's apparatus is constructed in such a manner, that, 
if a solution of glucose is employed, the length of the tube m being 
10 cm., every entire line of division on the scale will indicate 1 per 
cent, of sugar. 

The tube of the saccharimeter should be carefully washed out with 
distilled water, and at least once or twice with the filtered urine, 
when it is placed on end upon a flat surface, and filled with the urine, 
such that this forms a convex cup at the end. The little glass 
plate is now carefully adjusted, so as to guard against the admission 
of bubbles of air. The metallic cap is then placed in position, care 
being taken to avoid undue pressure. The examinations are made 
in a dark room ; an ordinary lamp is used, and several readings are 
taken, until the differences do not amount to more than one-tenth or 



THE CHEMISTRY OF THE URINE. 421 

two-tenths per cent. The tubes should be thoroughly cleansed im- 
mediately after the experiment. 

In every case the filtered urine should be free from albumin, and, 
if markedly colored, previously treated with neutral acetate of lead 
in substance and filtered. 

If it is desired to demonstrate only the presence of sugar, the com- 
pensators are first brought to the zero-position. If now, upon the 
interposition of the tube filled with urine, a difference in the color of 
the two halves of the field of vision is noted, the presence of an op- 
tically active substance in the urine may be assumed, and if the devi- 
ation is at the same time to the right, the presence of glucose is ren- 
dered highly probable, while a deviation to the left will generally 
be referable to levulose or /3-oxybutyric acid. Indican, peptones, 
cholesterin, and certain alkaloids, it is true, also turn the plane of 
polarization to the left, but as a rule these substances need not be 
considered, as cholesterin occurs but rarely, and indican is usually 
present in only small amounts in diabetic urines ; a concurrence of 
sugar and peptones, moreover, has not as yet been observed. Lactose 
and maltose, which also turn the plane of polarization to the right, 
may be distinguished from each other and from glucose by the 
phenylhydrazin test. Levulose turns the plane of polarization to the 
left. Oxybutyric acid is practically always associated with the pres- 
ence of glucose, and may be recognized by allowing the urine to un- 
dergo fermentation, when the filtered urine will become distinctly 
gyro-rotatory. 

Bremer's Diabetic- Urine Test. — The test is based upon the 
different behavior toward certain anilin dyes of diabetic, as compared 
with non-diabetic urine. If a trace of a mixture of 2 parts of eosin 
and 3 parts of gentian-violet, for example, is added to non-diabetic 
urine, it will be observed that the urine gradually dissolves the eosin 
and assumes a yellowish or bright red color, while the gentian-violet 
fails to dissolve. If diabetic urine, on the other hand, is treated in 
the same manner the eosin will likewise dissolve, but a dissolution of 
the gentian-violet also occurs, and the entire specimen eventually 
assumes a violet color. 

Of late Bremer has advised the use of Merck's gentian-violet B. or 
of methyl-violet 5B. The test is extremely simple : Two well-dried 
test-tubes are filled to about one-half, the one with normal urine and 
the other with the urine to be examined. About 0.5 mgrm, oi' either 
of the above reagents is then placed upon the surface of the urine, when 
the tubes are set aside in a warm place, or immersed in warm water. 
On standing it will be observed that strands of blue gradually appear 
in both specimens, but that the color disappears again in the normal 
specimen, on shaking, while in the diabetic urine the entire fluid 
assumes a blue or violet color. A reddish-purplish color is ot'ten 



422 THE URINE. 

observed in non-diabetic specimens, bat is of no significance. Bremer 
admits that doubtful results may be obtained with urines presenting 
an abnormally low specific gravity, viz, below 1.014 or 1.015, and 
that in such cases it may be impossible to distinguish non-diabetic 
from diabetic urine. He claims, on the other hand, that a positive 
result with a urine of high specific gravity is pathognomonic of dia- 
betes, and that this may be obtained even at a time w 7 hen the sugar 
has temporarily disappeared from the urine. 

The substance which gives rise to this peculiar reaction is as yet 
unknown. Sugar in itself, as also acetone and diacetic acid, are not 
concerned in its production. The reaction of the urine also is unim- 
portant. Bremer is inclined to believe that in non-diabetic urines 
one of the coloring principles helps to render the urine refractory. 
As he says, the colorless diabetic urines yield the most striking color 
reactions, and especially those in which a greenish shimmer is ap- 
parent. 

On the whole, Bremer's observations have been confirmed, so far 
as diabetic urine is concerned. Exceptions, however, occasionally 
occur even in cases of true diabetes, and, as Bremer admits, positive 
results are frequently observed in urines of a low specific gravity. 

The test is of interest and may possibly be further modified, so as 
to be of specific value in diagnosis, but as yet it would scarcely be 
warrantable to draw definite conclusions from its occurrence, even 
when the specific gravity is high. 

Lactose. — Lactose may be found in the urine toward the end of 
gestation, but more especially in nursing-women in whom the flow 
of milk is impeded, owing to the existence of mastitis, for example. 
It has also been stated that lactosuria occurs in nursing-women w T ho 
have well-developed breasts, in the absence of any obstruction, and 
that the good qualities of a wet-nurse are indicated by a copious and 
persistent elimination of milk-sugar. Its presence may be inferred 
if a positive result is obtained with Trommer's and Nylander's tests, 
while the phenylhydrazin and fermentation-tests give negative re- 
sults, although an osazon can be obtained from the pure substance, 
and although this undergoes a certain form of alcoholic fermentation. 

Lemaire, who has recently investigated this subject, found that 
the urine of nineteen women, examined in this direction, apparently 
contained no sugar during the last twelve days preceding confine- 
ment (Trommer's and Nylander's test), while a positive reaction was 
obtained with Trommer's reagent in two cases, and with Nylander's 
reagent in thirteen cases after confinement. The phenylhydrazin 
test was negative in all nineteen before and positive after confine- 
ment, ivhen this was directly applied to the substance, isolated according 
to Baumann's method. The percentage varied between 0.013 and 
0.438 per cent., and appeared to be uninfluenced by the act of nursing. 



THE CHEMISTRY OF THE URINE. 423 

Levulose. — Levulose is occasionally found in diabetic urines to- 
gether with glucose. Its presence is often indicated by the fact that 
a polarimetric examination shows a deviation to the left or none at 
all, while the other tests for sugar indicate the presence of a reducing 
substance. 

Maltose. — Maltose together with glucose was found in the urine 
of a patient, supposedly the subject of pancreatic disease, associated 
with an acholic condition of the stools. Its recognition is practically 
dependent upon the formation of its osazon and a determination of 
the melting-point of the latter. 

Dextrin. — In one case of diabetes dextrin appeared to take the 
place of glucose. It may be recognized by the fact that upon the 
application of Fehling's test the blue liquid first becomes green, 
then yellow and sometimes dark brown. 

Laiose. — Laiose occurs at times in the urine of diabetic patients. 
It is essentially characterized by the fact that by titration with 
Fehling's solution from 1.2 to 1.8 per cent, more sugar is indicated 
than by the polarimetric method. 

Pentoses. — To judge from recent observations, traces, of pentoses, 
viz, xylose, arabinose, and rhamnose, may be found in every urine. 
Larger quantities were first observed by Salkowski and Jastrowitz 
in the urine of a morphin habitue where the pentosuria alternated 
with glycosuria. A similar case was reported by Reale ; and Kiilz 
and Vogel found large quantities in diabetes. A digestive pento- 
suria has also been described. Such urines reduce Fehling's solu- 
tion, and give rise to the formation of an osazon when treated with 
phenylhydrazin. The osazon, however, can be readily distinguished 
from that obtained from glucose, maltose, or lactose, etc., by the 
melting-point. The fermentation-test is negative. Arabinose and 
rhamnose turn the plane of polarization to the right, while xylose 
remains indifferent. When present in notable amounts they are 
readily detected with Tollens' orcin-reagent. 

To this end orcin is dissolved in 5 to 6 c.c. of concentrated hydro- 
chloric acid by the aid of heat, so that a slight excess is present. 
This solution is divided into two equal parts and allowed to cool. 
To one portion 0.5 c.c. of the urine to be examined is added, and 
to the other an equal amount of normal urine of the same specific 
gravity. Both specimens are placed in a beaker containing boiling 
water, when in the presence of pentoses a green color will first be 
observed at the top, which gradually extends throughout the mix- 
ture, while the normal specimen scarcely changes in color. In the 
presence of 0.1 per cent, a positive reaction is still obtained, which 
is especially marked if the urine has been previously decolorized 
with animal charcoal. 

To/fen's phloroglucin test, in which phloroglucin is substituted for 



424 THE URINE. 

the orcin, and in which a deep red color is obtained in the presence 
of pentoses, may also be used, but indicates the presence of glycuro- 
nates as well. 

Animal Gum. — Animal gum, according to modern researches, is 
a constant constituent of normal urine, but of no clinical interest. 

Inosit. — Inosit does not occur normally in the urine, but may be 
demonstrated after the ingestion of large amounts of water. Patho- 
logically it has been found in cases of diabetes insipidus and in 
albuminuria. 

Still other carbohydrates are supposed to occur in the urine under 
various pathologic conditions, but nothing is known of their true 
nature that is definite, and it is questionable, indeed, whether they 
are carbohydrates. Ewald thus relates of the urine of a diabetic 
patient, which reduced Fehling's and Nylander's solution, which 
formed an osazon and underwent fermentation, while the polari- 
metric test was negative, and a pentose reaction could be obtained. 
Strauss further states that after the ingestion of hundred grammes 
of glucose he has repeatedly observed urines, Avhich reduced copper 
and bismuth, but which did not undergo fermentation and were op- 
tically inert or rotated the plane of polarization to the left. Whether 
or not this peculiar behavior of the urine can be attributed to the 
presence of certain glycuronic compounds or not, as Mayer suggests, 
remains to be seen. Similar observations are recorded by Blumen- 
thal and others. 

Glycuronic Acid. 

Glycuronic acid is derived from glucose, and constitutes an inter- 
mediary product of the normal metabolism of the body. In the 
urine it is only found in combination with certain fatty and aromatic 
alcohols, forming compounds, which are related to the glucosides, 
and are generally spoken of as the conjugate glycuronates. Such 
bodies have been observed in the urine, following the ingestion of 
chloral, camphor, naphtol, oil of turpentine, menthol, phenol, mor- 
phin, etc., and it also appears that traces may be obtained from nor- 
mal urines. The normal glycuronates are undoubtedly compounds 
of glycuronic acid with phenol, paracresol, indoxyl, and skatoxyl. 
Their amount, however, is exceedingly small, as the greater portion 
of these bodies is normally eliminated in combination with sulphuric 
acid. 

Of the quantitative variations of the normal glycuronates and 
their relation to disease next to nothing is known. Their clinical 
interest centres in the fact that certain glycuronates are capable of 
reducing copper and bismuth in alkaline solutions, and may thus be 
confounded with glucose. Such urines, however, do not undergo 
fermentation. The glycuronates turn the plane of polarization to the 



THE CHEMISTRY OF THE URINE. 425 

left, while glycuronic acid itself is dextro-rotatory. Like the pen- 
toses the glycuronates give a positive reaction with phloroglucin, 
while they do not react with orcin (see p. 423). With the free acid 
phenylhydrazin forms crystalline compounds (see p. 413). 

Urinary Pigments and Chromogens. 

In considering the subject of urinary pigments it is necessary to 
differentiate sharply between such pigments which occur preformed 
in the urine, and others that only appear upon the addition of cer- 
tain reagents which have the power of decomposing their chromo- 
gens. Until quite recently this s abject was in a most confused con- 
dition, and even now our knowledge can only be regarded as 
rudimentary ; for, notwithstanding the fact that numerous investiga- 
tions have been made with a view of determining the source of the 
color of normal urine, this problem, even, is not yet definitely solved, 
and it is only possible to say at the present time that urochrome and 
possibly a certain indoxyl derivative are to some extent responsible 
for the normal color of the urine. 

Under normal conditions urochrome and uroerythrin, to which 
latter the red color of urate sediments is due, are the only known 
pigments which occur preformed in the urine, while indigo-red and 
indigo-blue, derived from indoxyl sulphate and indoxyl glycuronate, 
may be artificially produced. In disease, on the other hand, various 
other pigments may be found, which occur in the urine either free or 
in the form of chromogens. Among the former may be mentioned 
haemoglobin, methsemoglobin, hsematin, hsematoporphyrin, urorubro- 
hsematin, urofuscohsematin, urobilin, the biliary pigments and melanin, 
while abnormal chromogens are met with following the ingestion of 
certain drugs, such as santonin, senna, rheum, iodine, etc., as also in 
cases of poisoning with carbolic acid, creosote, etc. The occurrence 
of some of these substances, such as the various forms of blood-pig- 
ment, the biliary pigments and indigo, viz, indican, is of considerable 
clinical interest, while others again are only of minor importance. 

Normal Pigments. — Urochrome. — To the presence of this pig- 
ment, which appears to be identical with the normal urobilin of Mac- 
Mu nn, but which should not be confounded with the pathologic urobilin 
of Jaffe, the normal yellow color of the urine is partly due. It is 
undoubtedly derived from bilirubin, which in turn is referable to the 
haematm and haemoglobin of the blood. From the bilirubin secreted 
into the intestinal tract it is derived by a process of oxidation, and 
not of reduction, as is generally stated. Such a transformation, ac- 
cording to our present knowledge, may, however, also occur directly, 
without the intervention of bilirubin, as urochrome is found in the 
urine of dogs, in which the bile is prevented from entering the in- 



426 THE URINE. 

testinal tract by the establishment of a biliary fistula. An increased 
amount is similarly found in cases in which a resorption of large 
extravasations of blood is taking place — in short, whenever an in- 
creased destruction of red corpuscles is noted. Under the opposite 
circumstances — i. e., in conditions associated with a new formation of 
red corpuscles, as in certain forms of anaemia, chronic parenchyma- 
tous nephritis, diabetes, diseases of the bone marrow, etc., it occurs 
in diminished amount. 

In order to obtain urochrome from normal urine this is acidulated 
with 1-2 grammes of dilute sulphuric acid pro litre, filtered, and 
saturated with ammonium sulphate in substance, when the flakes 
which are found, if an excess of the salt has been added, are dried 
and treated with warm, slightly ammoniacal absolute alcohol ; the 
pigment is then obtained upon evaporation of the alcohol. An alco- 
holic solution of urochrome, like the urobilin of Jaffe, exhibits a 
beautiful greenish fluorescence, when treated with ammonia and a 
few drops of a solution of zinc chloride, but, unlike the latter sub- 
stance, its acidulated alcoholic solutions present a broad band of 
absorption at " F," which extends more to the left than to the right 
of this line, while the remainder of the spectrum is at the same time 
absorbed to the right end, from a point somewhat to the left of " G." 

Uroerythrin. — Uroerythrin is the pigment which imparts the 
red color to crystals of uric acid and urate sediments. In pathologic 
conditions it is seen especially in cases of hepatic insufficiency, in 
which the liver, owing to a greatly increased destruction of red cor- 
puscles, is unable to transform all the blood-pigment which is carried 
to it into bile-pigment. It also occurs when an absolute insufficiency 
on the part of the hepatic cells exists, so that the organ is not even 
capable of causing the transformation of a normal amount of haemo- 
globin. Uroerythrin is thus seen in notable quantities in cases of 
pneumonia, malarial fever, erysipelas, spinal curvature, hepatic cir- 
rhosis, carcinoma of the liver, etc. Chemically, its close relation to 
haemoglobin, haematoidin, and bilirubin is seen from the following 
analyses of the various pigments : 

C H N O S Fe 

Haemoglobin, 53.85 7.32 16.17 0.39 0.43 

Haematoidin, 65.05 6.37 9.51 

Bilirubin, 67.83 6.29 9.79 16.79 

Uroerythrin, 62.51 5.79 3L70 

When present in large amounts uroerythrin is readily recognized 
by the salmon-red color w r hich it imparts to urinary sediments. 
Otherwise it is best to precipitate the urine with neutral acetate of 
lead, barium chloride, or a similar reagent, w r hen in the absence of 
uroerythrin a milky-white precipitate is obtained, while a pale rose- 



THE CHEMISTRY OF THE URINE. 427 

colored sediment indicates the presence of the pigment in appreciable 
amounts ; a more pronounced rose-color is produced if large quanti- 
ties are present. In every case at least ten to fifteen minutes should 
be allowed to elapse before forming a definite conclusion, so that the 
sediment may have abundant time to settle. 

Normal Chromogens. — The chromogens occurring in normal urine 
are indican, urohsematin, and an unknown chromogen which yields 
urorosein when treated with mineral acids. 

Indican. — It has already been pointed out (see Sulphates) that 
the indol formed during the process of intestinal putrefaction is oxi- 
dized to indoxyl in the blood ; this, entering into combination with 
sulphuric acid, is eliminated in the urine as sodium or potassium 
indoxyl-sulphate, or indican, as represented by the equations : 

Indol. Indoxyl. 

I. C 8 H 7 N + O = C 8 H 7 NO 

Indoxyl. Indoxyl-sulphate. 



/OH /CANO 

II. C 8 H 7 NO + S0 2 < =S0 2 < 



/^ 



x OH x OH 

Indoxyl-sulphate. Indoxvl-sodium sulphate. 

/C 8 H 6 NO V C 8 H s N0 

III. S0 2 < +Na,HP0 4 = S0 2 < + NaH 2 P0 4 

\OH \ONa 

Formerly it was thought that indican was also formed within the 
tissues of the body, in the absence of putrefactive organisms (this 
view was held especially by Salkowski), Further researches, how- 
ever, have demonstrated beyond a doubt that micro-organisms are 
always concerned in the production of indican, and that in health the 
large intestine is its only source. Baumann, who succeeded in abso- 
lutely disinfecting the intestinal tract of a dog by means of large 
doses of calomel, thus observed that all traces of indican, as also of 
phenol and paracresol, disappeared from the urine. According to 
Senator, moreover, indican does not occur in the urine of newly born 
infants which have not as yet received nourishment. This observa- 
tion is a strong point in favor of Nencki's teachings that indol is a 
specific product of albuminous putrefaction, in the presence of organ- 
ized ferments, as putrefiable substances are present, but no putrefac- 
tive organisms. Tuczek's observations on abstinence from food in 
cases of insanity, in which indican was only observed in the urine 
when albumins, though in minimal amounts, wore ingested, also 
speak very strongly against Salkowski's theory. Finally it has been 
demonstrated that in cases, in which an artificial anus is established 
near the distal end of the ileum, the conjugate sulphates disappear 
almost entirely from the urine, while they reappear in normal amount. 



428 THE URINE. 

as soon as the connection between the small and large intestines has 
been reestablished. 

The amount of indican which is normally eliminated in the urine 
varies somewhat with the character of the diet. Jaffe obtained 6.6 
milligrammes from 1,000 c.c. of urine, as an average of eight obser- 
vations. The largest quantities excreted in health are found after a 
liberal indulgence in animal food, particularly the so-called red 
meats, while the smallest amounts are observed during a milk or 
kefir diet. By means of the latter article, indeed, the greatest dimi- 
nution in the degree of intestinal putrefaction may be effected in 
man. In pathologic conditions an increased elimination of indican 
is observed : 

1. In all diseases which are associated with an increased degree of 
intestinal putrefaction. As there appears to be little doubt that this 
is largely regulated by the acidity of the gastric juice, an increased 
indicanuria, according to personal observations, is encountered when 
anachlorhydria or hypochlorhydria exist. It has been pointed out 
elsewhere that it is possible to form a fairly accurate idea of the 
amount of free hydrochloric acid in the gastric juice by an examina- 
tion of the urine in this direction. Large quantities of indican are 
thus eliminated in cases of carcinoma of the stomach, and exceeded 
only by those observed in cases of ileus, so that this symptom, in my 
estimation, is one of considerable value in differential diagnosis, and 
one, moreover, which has not as yet received the attention which it 
undoubtedly deserves. Exceptions to this rule are at times, though 
rarely, met with, for which it is, however, impossible to account at 
the present time. Large quantities of indican are also observed in 
cases of acute, subacute, and chronic gastritis, of whatever origin. 
In the course of personal observations in this direction, I was struck 
with the curious phenomenon that in cases of ulcer of the stomach, 
notwithstanding the simultaneous occurrence of hyperchlorhydria, an 
increased elimination of indican, contrary to what is usually seen in 
hyperchlorhydria referable to other causes, is quite constantly found. 
Possibly the existence of muscular atony which was noted in those cases 
may serve to explain this apparent incongruity, but it is as yet im- 
possible to offer a satisfactory explanation of the phenomenon. Re- 
membering the origin of indican, and the relation which the amount 
eliminated bears to the degree of intestinal putrefaction, it will be un- 
necessary to enumerate the long list of diseases in which an increased 
indicanuria has been observed, as it will be found that in the majority 
of these cases the indicanuria is merely an index of the condition of 
the gastric juice and the motor power of the stomach. 

2. It should be noted that in cases in which the peristaltic move- 
ments of the small intestine have become impeded, as in ileus, acute and 
chronic peritonitis, an increased elimination of indican will inva- 



THE CHEMISTRY OF THE URINE. 429 

riably take place, no matter what the state of the gastric juice may 
be. In such conditions, and especially in ileus, the largest quanti- 
ties are observed, a point which may be of decided value in differ- 
ential diagnosis, as diseases of the large intestine, alone, are never 
associated with an increase in the amount of indican. In simple, un- 
complicated constipation increased indicanuria is not seen, and should 
an examination in such cases reveal the presence of more indican 
than normal, it will be safe to assume the existence of disease else- 
where, and especially of the stomach. 

3. As albuminous putrefaction can also take place within the body, 
an increased indicanuria is observed in cases of empyema, putrid 
bronchitis, gangrene of the lungs, etc.; but while in the conditions 
mentioned above the indol-producing organisms appear to be espe- 
cially active, the elimination of phenol in the latter condition may be 
more pronounced at times than that of indican. Bearing in mind 
the points here set forth, I cannot agree with others in saying that the 
study of indicanuria possesses no importance from a clinical stand- 
point. I maintain, on the other hand, that an examination of the 
urine in this direction is at least as important, as the testing for albumin 
and sugar, and that points of decided importance, not only in diagnosis 
but cdso in prognosis and treatment can thus be gained. 

When indican is treated with hydrochloric acid it is decomposed 
into sulphuric acid and indoxyl ; should an oxidizing substance be 
present at the same time, indigo-blue, the blue coloring-matter of the 
urine, results : 

Potassium indoxyl Indigo-blue, 

sulphate. 

2C 8 H 6 NKSO i + 20 = C 16 H 10 N 2 O 2 + 2HKS0 4 . 

Indigo-blue in small amounts may be found free in the sediment 
of almost every decomposing urine, usually occurring in the form of 
small, amorphous granules, and more rarely in crystalline form. 
Urines have, however, also been observed which were blue when 
passed, or which turned blue, as a whole, upon standing. Such a 
phenomenon must be regarded as a medical curiosity. 

The blue pigment which may be obtained from urines has been 
variously described as Prussian-blue, urocyanin, cyanurin, Harnblau, 
uroglaucin, choleraic urocyanin, but has been ultimately shown to be 
indigo-blue, and derived from a colorless mother-substance which is 
present in every urine to a greater or less extent, and which has been 
named indican. This has been shown to be identical with the uro- 
xanthin of Heller and Thudichum's choleraic urocyaninogen. 

Tests for Indican. — The urine of twenty-four hours is carefully 
collected and a specimen taken lor examination. A lew cubic cen- 
timetres are then mixed with an equal volume of Ohermaver's re- 



430 THE URINE. 

agent, and shaken with a small amount of chloroform. Obermayer's 
reagent is a 2-pro-mille solution of the sesquichloride of iron in 
concentrated hydrochloric acid. 

Stokvis' modification of Jaife's test may also be employed. To 
this end a few c.c. of urine are treated with an equal volume of con- 
centrated hydrochloric acid, and two or three drops of a strong solu- 
tion of sodium, or calcium hypochlorite. The mixture is shaken 
with one or two c.c. of chloroform as above. The indigo which is 
set free in this manner is taken up by the chloroform, and colors 
this blue to a greater or less extent, the degree of increase, as com- 
pared with the normal, being determined by the intensity of the 
color. Albumin need not be removed. Bile-pigment, which inter- 
feres with the reaction, is removed by means of a solution of sub- 
acetate of lead which is carefully added in order to avoid an excess. 
Urines presenting a very dark color may be cleared in the same 
manner. Potassium iodide, owing to the liberation of free iodine, 
will color the chloroform more or less of a carmine. For the sake 
of comparison, it is well to employ the same quantities of urine and 
reagents in every case, marked tubes being very convenient for this 
purpose. 

The method, which' I have last described, I have also found to be 
a fairly sensitive test for albumin, in the presence of which a well- 
marked cloud appears near the surface of the mixture, and gradually 
extends downward. 

Quantitative Estimation. — Wang's Method. — The method is 
based upon the decomposition of potassium indoxyl sulphate by 
means of concentrated hydrochloric acid and the oxidation of the 
indoxyl, which is thus formed, to indigo-blue. This is further trans- 
formed into indigo-sulphuric acid, and thus titrated with a solution 
of potassium permanganate of known strength. The various changes 
which take place are represented by the following equations : 

Indican. Indoxyl. 

I. C 8 H 6 NS0 4 K + H 2 = C 8 H 6 N.OH + HKS0 4 

Indoxyl. Indigo-blue. 

II. 2C 8 H 6 N.OH + 20 = C 16 H 10 N 2 O 2 4- 2H 2 

Indigo-blue. Indigo-sulphuric acid. 

III. C 16 H 10 N 2 O 2 + 2H 2 S0 4 = C 16 H 8 (HS0 3 ) 2 N 2 2 + 2H 2 

Indigo-blue. 
IV. 5C 16 H 10 N 2 O 2 + 4KMn0 4 + 6H 2 S0 4 = 5C 16 H 10 N 2 O 4 + 2K,S0 4 + 4MnS0 4 — 6H 2 

Reagents required : 1. A 20-per-cent. solution of acetate of lead. 

2. Obermayer's reagent. This is a 2-pro-mille solution of the ses- 
quichloride of iron in concentrated hydrochloric acid (sp. gr. 1.19). 

3. Chloroform. 

4. Concentrated sulphuric acid. 



THE CHEMISTRY OF THE URINE. 431 

5. A mixture of equal parts of alcohol (96 per cent.), ether and 
water. 

6. A concentrated solution of potassium permanganate (i. <?., a 
solution containing about 3 grammes pro litre). The titration is con- 
ducted with this solution, dilated in the proportion of 5 c.c. to 195 
c.c. of water. Its titre is ascertained before each titration, by com- 
paring it with a dilute solution of oxalic acid of known strength ; for 
example, one containing, 0.1 gramme of the acid, dissolved in 100 c.c. 
of water, as described on p. 353. The amount of indigo-blue which 
each c.c. will represent, is ascertained by multiplying the correspond- 
ing amount of oxalic acid by 1.04. 

Example. — Supposing that the permanganate solution is found 
of such strength that one c.c. represents 0.00014 gramme of oxalic 
acid; the corresponding amount of indigo would be 0.00014 x 1.04 
= 0.00015 gramme. 

Method. — The urine is first examined for indican, as described 
above. Should a very intense reaction be thus obtained, only 25 or 
50 c.c. are used for the quantitative estimation, while larger amounts 
are taken (200—500 c.c), if the reaction is only of moderate intensity 
or negative altogether. 

The urine is then precipitated with the acetate of lead solution, 
care being taken to avoid an excess. A large and accurately meas- 
ured portion of the clear filtrate is treated, in a separating funnel, 
with an equal volume of Obermayer's reagent and extracted with 
chloroform. To this end 30 c.c. are added at a time and shaken for 
one minute. Two or three extractions are usually sufficient to re- 
move the entire amount of indigo. The extract is placed in a small 
flask, when the chloroform is distilled off. The residue is dried for 
a few minutes on the water bath, until all vapors of the chloroform 
have been removed. It is then washed with the alcohol-ether and 
water mixture to remove the reddish-brown pigment, which is pres- 
ent together with the indigo-blue. The latter remains undissolved. 
After filtering off any particles of indigo that may be in suspension, 
through a small filter, this is dried and repeatedly extracted with 
boiling chloroform. The chloroform extract is filtered into the 
original indigo flask, the chloroform is distilled off, the residue dried, 
as before, and treated with three or four c.c. of concentrated sulphuric 
acid, Avhile still warm. The entire residue should be brought into 
solution by careful agitation. After standing for 24 hours the eon- 
tents of the flask are poured into 100 c.c. of cold water ; the flask is 
rinsed out and the washings added to the solution. This is then 
filtered once more and titrated with the permanganate solution. At 
first the blue color of the solution changes but little ; Later it turns 
greenish, and finally becomes yellowish or entirely colorless — not 
red. As a rule the end reaction is quite distinct, but the titration 



432 THE URINE. 

requires a certain amount of experience nevertheless. The best re- 
sults are obtained when from 10-15 c.c. of the dilute permanganate 
solution are used. The resulting amount of indigo, contained in the 
measured-off quantity of the first filtrate, is then ascertained as de- 
scribed above. 

Example. — Amount of urine : 1,780 c.c. 

The stock solution of potassium permanganate contains 3 grammes 
to the litre ; 1 c.c. = 0.00596 gramme of oxalic acid = 0.0062 
gramme of indigo. Diluted solution (5:200); 1 c.c. = 0.00015 
gramme of indigo. 300 c.c. of urine were precipitated with 25 c.c. 
of the lead solution ; 250 c.c. of the filtrate corresponding to 230.7 c.c. 
of urine, treated with 250 c.c. of Obermayer's reagent. Extracted 
twice with chloroform. 4.3 c.c. of the permanganate solution were 
used in the titration = 0.00065 gramme of indigo, corresponding to 
0.005 gramme in the 1,780 c.c, according to the equation : 

230.7 : 0.00065 : : 1780 : x ; x = ]^i =0.005. 

230./ 

Other methods for the quantitative estimation of indican, which 
have heretofore been in use, with the exception of the spectroscopic 
method of Midler, are not only inaccurate, but like this, too lengthy 
and complicated to be of value to the practicing physician. As a 
consequence almost all observers have based their conclusions upon 
an approximative estimation only. For practical purposes this is 
indeed sufficient, and even Wang's method, though accurate and 
quite simple, will hardly find a ready entrance into the clinical 
laboratory, as it is both time-consuming and rather expensive for 
daily use. For scientific purposes, however, it can be recommended. 

Uroh^ematix. — Urohaematin appears to be the chromogen of the 
red pigment of the urine, and is very likely closely related to in- 
doxyl. Little is known of its chemical composition or of its mode 
of formation. In all probability the red pigment which may be ob- 
tained from this substance is identical with other red pigments, which 
have been described from time to time as occurring in the urine, such 
as that of Scherer, the urrhodin of Heller, the urorubin of Plosz, 
Schunk's indirubin, Bayer's indigo-purpurin, Giacosa's pigment, and 
also the indigo-red obtained by Eosenbach and Rosin by careful 
oxidation of the urine with nitric acid. 

Further investigations are necessary before this subject is fully 
understood, but bearing in mind the probable origin of urohsematin 
from indoxyl, it would possibly be best to speak of the red pigment 
as indigo-red. 

The presence in normal urine, of urohsematin, — i. e., a chromogen 
yielding a red pigment when treated with certain reagents, — may be 



THE CHEMISTRY OF THE URINE. 433 

demonstrated by shaking urine with chloroform and decanting after 
several days, when the addition of a drop of hydrochloric acid to the 
chloroform extract will cause the appearance of a beautiful rose-color ; 
this varies in intensity according to the amount of the chromogen 
present. 

In accordance with the view that urohaematin is an indoxyl deriva- 
tive, its clinical significance is similar to that of indican (which see). 
The purplish color so often obtained in the chloroform extract, when 
Stokvis' modification of Jaffe's indican test is employed, is due to a 
mixture of indigo-blue and indigo-red. Indican, however, is gener- 
ally present in larger amounts than urohaematin. In normal and, 
usually also, in pathologic urines a red color is not obtained with the 
test mentioned. In a few isolated cases of ileus, peritonitis, and car- 
cinoma of the stomach I have found more indigo-red than indigo- 
blue. 

The so-called " Reaction of Rosenbach " is a convenient test for 
indigo-red, when this is present in increased amounts : the boiling 
urine is treated, drop by drop, with concentrated nitric acid, when in 
the presence of large amounts of indigo-red it will assume a dark 
Burgundy color, which sometimes takes on a bluish tinge if held to 
the light. Owing to a precipitation of the pigment the mixture at 
the same time becomes cloudy, and the foam assumes a blue color. 
In well-marked cases the Burgundy color does not appear to be 
changed by the further addition of nitric acid, but will sometimes, 
when 10—20 drops of the acid have been added, suddenly turn from 
red to yellow. This reaction Rosenbach regarded as symptomatic of 
various forms of severe intestinal disease, associated with an impeded 
resorption throughout the entire intestinal tract. Ewald likewise 
noted this reaction in cases of extensive disease of the small intestine, 
in carcinoma of the stomach, acute and chronic peritonitis, but ob- 
tained negative results in carcinoma of the colon, stricture of the 
oesophagus, chronic diarrhoea, etc. Rosenbach's reaction should be 
viewed in the same light as a highly increased elimination of indican. 
I have met with the reaction in all conditions associated with greatly 
increased intestinal putrefaction, and, like EAvald, failed to note the 
reaction in a few cases of occlusion of the large intestine, in which 
an increased elimination of indican is likewise never observed. 

Uroroseinogen. — In addition to indican and urohaematin still 
another chromogen, which yields a rose-red pigment when treated 
with mineral acids, appears to occur in normal urine, although in 
small amounts. Beyond the fact that the chromogen is not a conjugate 
sulphate, practically nothing is known of its chemical nature. The 
pigment, which has received the name urorosein 3 or Hamrosa, ap- 
pears to be identical with Heller's urophain. Urorosein is best dem- 
onstrated by treating 5-10 c.e. of urine witli an equal amount of 
28 



434 THE URINE. 

concentrated hydrochloric acid, and 1 or 2 drops of a concentrated 
solution of bleaching-powder, when in the presence of much indican 
the mixture first assumes a dark-greenish, blackish, or dark-blue color, 
owing to the formation of indigo. When the mixture is then shaken 
with chloroform the supernatant fluid will exhibit a beautiful rose- 
color, which is due to the urorosein. This may now be extracted with 
amyl alcohol and separated from other pigments, which are present 
at the same time, by shaking with sodium hydrate, whereby the solu- 
tion is decolorized. Upon the addition of a drop or two of hydro- 
chloric acid to the alcoholic extract the rose-color will reappear. Such 
solutions, however, soon become decolorized upon standing. A rose- 
red ring, referable to this pigment, is also frequently obtained in 
pathologic urines, when the ordinary nitric-acid test is employed. 

While normally urorosein can only be obtained in traces, appre- 
ciable amounts are often met with in pathologic conditions, associated 
with grave disturbances of nutrition, as in nephritis, diabetes, carci- 
noma, dilatation of the stomach, pernicious anaemia, typhoid fever, 
phthisis, and at times in profound chlorosis, etc. A vegetable diet 
also appears to cause an increase in the amount of the chromogen. 

Pathologic Pigments and Chromogens. — The Blood Pigments. 
— The blood-pigments proper, which may occur in the urine have al- 
ready been considered (see p. 400), and in this connection it will 
only be necessary to refer briefly to the occasional presence of hsem- 
atin, urorubrohsematin, urofuscohsematin, and hsematoporphyrin. 

HiE matin is only rarely seen. In order to demonstrate its pres- 
ence, the urine is rendered strongly alkaline with ammonia, filtered, 
and the filtrate examined spectroscopically, when the spectrum shown 
in Fig. 6 will be noted ; this may be changed into the spectrum rep- 
resented in Fig. 7 by the addition of ammonium sulphide. 

Urorubroh.ematin and Urofuscoh^matin are two pigments 
which were observed by Baumstark in the urine of a case of pem- 
phigus leprosus, complicated with visceral lepra ; they appear to be 
closely related to hseinatin. The color of the urine in this case 
varied between dark-red and brownish-red, strongly suggesting the 
presence of blood. In order to separate the pigments the urine w T as 
dialyzed and the contents of the dialyzer dissolved in sodium hy- 
drate solution. Upon the addition of hydrochloric acid to this 
solution a brown pigment separated out in flakes, while a second 
pigment remained in solution, imparting to it a beautiful red color. 
Upon filtration the acid filtrate was again subjected to dialysis, 
when the red pigment likewise separated out. The former substance 
Baumstark termed urorubrohsematin, and the latter urofuscohseruatin. 

Uroilematoporphyrin has the formula C 16 H 18 N 2 3 ; it is prob- 
ably closely related to the hsematoporphyrin resulting from the action 
of sulphuric acid upon hsematin. MacMunn found a pigment an- 



THE CHEMISTRY OF THE URINE. 435 

swering the description of this substance in the urine in cases of rheu- 
matism, Addison's disease, pericarditis, and paroxysmal hemoglo- 
binuria, which he termed urohsematin, but which in all probability 
was hsematoporphyrin. Le Nobel found the same pigment in two 
cases of hepatic cirrhosis and in one case of croupous pneumonia. 
More recently hsematoporphyrin has been repeatedly noted in the 
urine during a long-continued administration of sulphonal, trional, 
and tetronal, as also in cases of lead-poisoning and intestinal hemor- 
rhages. Clinically its occurrence does not appear to be of any diag- 
nostic significance, and recent researches have shown that in traces, 
at least, it is present in every urine. Urines rich in hsematopor- 
phyrin present an abnormal color, varying from a sherry or port- 
wine tint to Bordeaux. Albumin in uncomplicated cases is not 
present, and hsematoporphyrin itself does not give the albumin re- 
actions. In urines presenting the color just described hsematopor- 
phyrin may be tested for in the following manner : 

Thirty c.c. of urine are treated with an alkaline solution of barium 
chloride. The precipitate, after having been washed with water and 
then with absolute alcohol, is extracted with ordinary alcohol, acidu- 
lated with hydrochloric acicl, by rubbing in a mortar. The solution 
thus obtained will present a reddish color in the presence of hsema- 
toporphyrin, and its filtrate yield the characteristic spectrum of the 
latter substance ; i. e., four bands of absorption, of which two are 
broad and dark and two light and narrow. The former alone are 
characteristic, and frequently the only ones visible. One of these 
extends beyond " D " into the red portion of the spectrum, while the 
other is situated between " b " and " F." Of the other two bands, 
one may be seen between "■ C " and " D," and the other between 
"D" and "E," nearer «E" (Fig. 10). 

In conclusion it may be said that a chromogen of hsematoporphyrin 
is also usually present in urines containing the free pigment, which 
probably explains why such urines gradually become darker on 
standing. 

Biliary Pigments. — Of the four biliary pigments, viz, bilirubin, 
biliverdin, biliprasin, and bilifuscin, the former alone is met with in 
freshly voided urines, while the others may form upon standing, 
being oxidation-products of bilirubin. As this pigment is never 
found in normal urine, its occurrence may be regarded as a definite 
symptom of disease. 

In health, it will be remembered, that bilirubin, C 16 H 18 N 2 O s , formed 
in the liver from blood-pigment, is eliminated into the small intes- 
tine, in which it is transformed into hvdro-bilirubin and Largely ex- 
creted as such in the feces, while a small portion is reabsorbed into 
the blood and eliminated in the urine as urochrome or normal uro- 
bilin. Whenever, then, the out How of bile into the intestines be- 



436 THE URINE. 

comes impeded bilirubin is absorbed by the lymphatics and eliminated 
in the urine. 

Among the numerous causes which give rise to choluria, under 
such conditions, may be mentioned obstruction of the biliary ducts 
and especially of the common duct, referable to simple swelling of 
its mucous membrane, as in the ordinary forms of catarrhal jaun- 
dice. It may also be due to the presence of a biliary calculus, to 
parasites, compression of the duct by tumors of the liver, the gall- 
bladder, the duct itself, and of neighboring structures, and particularly 
of the pancreas, stomach, and omentum. Whenever the blood-pres- 
sure in the liver is lowered, so that the tension in the smaller biliary 
ducts becomes greater than that in the veins, choluria likewise re- 
sults. The icterus occurring under these conditions has been termed 
hepatogenic icterus, in contradistinction to the form observed in cases 
in which the liver has either totally or partially lost the power of 
forming bile, be this owing to the existence of degenerative processes 
affecting its glandular epithelium, as in cases of acute yellow at- 
rophy, or to destruction of red corpuscles going on so rapidly and 
so extensively that the organ is incapable of transforming into bil- 
irubin all the blood-pigment which is carried to it. This occurs in 
pernicious anaemia, malarial intoxication, typhoid fever, poisoning 
with arseniuretted hydrogen, etc. The icterus neonatorum is prob- 
ably to a certain extent also dependent upon the latter cause. To 
this form the term hematogenic icterus has been applied. In such 
cases the occurrence of bilirubin in the urine can only be explained 
by assuming, that a transformation of blood coloring-matter into 
bilirubin has taken place in the blood itself, or in other tissues of the 
body. As a matter of fact, it appears to be quite generally accepted 
that such a transformation can actually occur outside of the liver, as 
the hsematoidin which may be found in old extravasations of blood 
seems to be identical with bilirubin. On the other hand, however, 
the existence of a hematogenic icterus is positively denied, especially 
by Stadelmann. In accordance Avith his view it may be demon- 
strated that in cases of pernicious anaemia, malaria, etc., the urine 
does not contain bilirubin, but usually urobilin. In cases of this 
kind, which I had occasion to examine, bilirubin was never found. 
Further investigations are necessary to settle this question definitely. 

Usually the presence of biliary pigment may be recognized by 
direct inspection, as urines, which contain this in notable amounts, 
present a color varying from a bright yellow to a greenish-brown. 
Any morphologic elements which may occur in the sediment are 
stained a golden-yellow, and the same color is imparted to the foam 
of the urine, as well as to the filter -paper used in its filtration. At 
times, however, and particularly in cases in which the icterus is only 
beginning to appear, the presence of bilirubin is not infrequently 



THE CHEMISTRY OF THE URINE. 437 

overlooked, and urines containing urobilin in large amounts may be 
similarly mistaken for icteric urines. In doubtful cases, therefore, 
whether icterus exists or not, but in which the urine presents an 
intense yellow color, it is necessary to have recourse to chemical 
tests. A large number of these have been devised for the purpose 
of demonstrating the presence of bilirubin, all of which are fairly 
reliable. Only those will be described here which I have tested my- 
self and which are especially delicate. 

Smith's Test. — 5-10 c.c. of urine are placed in a test-tube and 
treated with 2 or 3 c.c. of tincture of iodine, which has been diluted 
with alcohol in the proportion of 1 : 10, in such a manner that the 
iodine solution forms a layer above the urine. In the presence of 
bilirubin a distinct emerald-green ring will be seen at the zone of 
contact. This test can be highly recommended, as it is exceedingly 
simple and not surpassed in delicacy by any other. 

Huppert's Test. — 10-20 c.c. of urine are precipitated with milk 
of lime (a solution of barium chloride is, perhaps, still more conve- 
nient), and the precipitate, after filtering, brought into a beaker by 
perforating the filter and washing its contents into the latter with 
a small amount of alcohol, acidulated with sulphuric acid. The 
mixture is boiled, when in the presence of bilirubin the solution 
assumes a bright emerald-green color. Huppert's test is as delicate 
as that of Smith, but not so convenient for the needs of the prac- 
tising physician. 

Gmelin's Test, as Modified by Rosenbach. — The urine is 
filtered through thick Swedish filter-paper, when the latter is re- 
moved and a drop of concentrated nitric acid, which has been allowed 
to stand exposed to the air for a short time, is placed upon its inner 
surface. In the presence of bilirubin, rings presenting the colors of 
the rainbow will be seen to form around the nitric acid. 

Gmelin's Test. — The urine is treated with nitric acid, which is 
carried to the bottom of the test-tube by means of a pipette, so as to 
form a layer beneath the urine, when a color-play, as already do- 
scribed (p. 390), will take place at the line of contact between the 
two fluids ; the green color is the most characteristic. 

In this connection a few words may also be said of the occurrence 
in the urine of biliary acids and cholesterin. 

Biliary Acids. — These may be demonstrated in the urine, whenever 
bile-pigment is present, so that their clinical significance is essentially 
the same as that attaching to bilirubin. Their demonstration is, how- 
ever, attended with such difficulties that the methods devised fortius 
purpose may well be omitted at this place (see also p. 205). 

Cholesterin. — Cholesterin has never been found in icteric urines, 
and is only rarely seen in other pathologic conditions. It has been 
observed in cases of chyluria, fatty degeneration o^ the kidneys. 



438 THE URINE. 

diabetes, in one case of epilepsy, and in two cases of pregnancy. 
v. Jaksch has noted the presence of cholesterin crystals in a urinary 
sediment in a case of tabes and cystitis. I have found cholesterin 
crystals in the sediment in a case of acute nephritis. The urine was 
of a dark amber-color, cloudy, of an acid reaction, and a specific 
gravity of 1.028. In the sediment numerous hyaline and epithelial 
casts and some red blood-corpuscles were found. Giiterbock described 
a urinary calculus obtained from the bladder of a woman which con- 
sisted almost entirely of cholesterin (see also Feces). 

Beginners at times regard the spangles of urea nitrate seen in 
urines rich in urea, after the addition of nitric acid, as choles- 
terin. 

Pathologic Urobilin. — This pigment should not be confounded with 
the urochrome or normal urobilin described above, to which it is 
closely related, but from which it may be readily distinguished by 
means of the spectroscope. Gautier states that pathologic urobilin 
may be obtained from urochrome by submitting the latter to the 
action of reducing agents. Like normal urobilin it is derived from 
the coloring-matter of the blood and bilirubin, and merely represents 
a lower form of oxidation than normal urobilin. It is said to be 
identical with the stercobilin found in the feces. While its occurrence 
in the urine is essentially a pathologic phenomenon, it is at times also 
met with in normal urines, and appears to be derived from a special 
chromogen, urobilinogen, from which it may be set free by the addi- 
tion of an acid. From its frequent occurrence in febrile urines 
pathologic urobilin has also received the name febrile urobilin. It is, 
however, also observed in many other conditions, and especially in 
cases presenting the so-called hematogenic form of icterus, from 
which fact, indeed, and the usual absence of bilirubin at the same 
time, this form has been termed " urobilin icterus/' In this connec- 
tion it is interesting to note that, according to v. Jaksch, bilirubin 
occurs in the blood in almost every case, in which urobilin is present 
in the urine, showing that bile-pigment circulating in the blood is in 
all probability transformed into urobilin in the kidneys. 

Urobilinuria has been observed in certain hepatic diseases ; in 
twelve cases of atrophic and hypertrophic cirrhosis, v. Jaksch 
was able to demonstrate the presence of urobilin in every instance, 
a point which at times may be of considerable diagnostic im- 
portance, providing that other causes which are known to lead to 
urobilinuria can be eliminated. I have observed urobilin in a few 
cases of hepatic cirrhosis, chronic malaria, and pernicious anaemia, in 
all of which the skin presented a light icteric hue, and in which bile- 
pigment was absent from the urine. An examination of the blood 
was, however, unfortunately not made. Urobilin has also been 
noted in cases of carcinoma, scurvy, Addison's disease, haemophilia, 



THE CHEMISTRY OF THE URINE. 430 

retro-uterine hematocele, extra-uterine pregnancy, following intra- 
cranial hemorrhages, etc. 

Urines which are rich in urobilin usually present a dark-yellow 
color, which is strongly suggestive of the presence of bilirubin ; the 
foam, even, in such cases may be colored, making the resemblance 
between the two pigments still more complete, v. Jaksch further 
points out that urines containing indican in large amounts often 
likewise present a very dark-yellow color, a statement with which 
my own observations are in perfect accord. It is possible that the 
color in such cases may be due to the presence of humin-substances 
derived from the indican. In every case a more detailed chemical 
examination should hence be made. The method suggested by v. 
Jaksch appears to be more serviceable than that suggested by Ger- 
hardt. 

v. Jaksch' s Test. — 10-20 c.c. of urine are submitted to Hup- 
pert's test (which see), when, in the presence of urobilin in notable 
quantities, the precipitate assumes a brownish-red color, which dis- 
appears upon boiling with acidulated alcohol, while the liquid is 
colored a brownish or pomegranate-red. In the presence of a small 
amount only of this pigment, on the other hand, the liquid is colored 
a light reddish tinge. 

Gerhardt's Test. — If the urine contains much urobilin, which 
the color will indicate, 10-20 c.c. are extracted with chloroform by 
shaking, and the extract treated with a few drops of a dilute solu- 
tion of iodo-potassic iodide. Upon the further addition of a dilute 
solution of sodium hydrate the chloroform extract is colored a yellow 
or yellowish-brown, and exhibits a beautiful green fluorescence ; this 
is even more intense than that noted in the case of normal urobilin. 

At times, however, all tests fail and recourse must then be had to 
the spectroscope. In acid solutions urobilin presents a distinct band 
of absorption between " b" and " F," extending beyond " F " to the 
right, while in alkaline solutions a band is likewise seen between " b" 
and " F," but does not extend beyond " F," and is less intense. 

Melanin and Melanogen. — In cases of melanotic disease it has been 
repeatedly observed that the urine, which usually and probably 
always presents a normal yellow color when voided, gradually 
becomes darker upon exposure to the air, and finally turns black. 
This phenomenon indicates, without a doubt, that such urines contain a 
chromogen, melanogen, which, upon oxidation, yields the black pig- 
ment noted in these cases viz, melanin. As yet it has not been pos- 
sible to isolate this substance in pure form, and it is, indeed, not 
definitely determined that the black color in such urines is referable 
to one single pigment. Such urines generally contain melanin and 
its chromogen in solution ; deposits of melanin granules by them- 
selves arc only occasionally seen, and are not at all characteristic, as 



440 THE URINE. 

they may also be found in cases of chronic malarial intoxication, etc., 
when they may, indeed, be met with in the blood, constituting the 
condition spoken of as melancemia. 

While the occurrence of melanin in the urine is probably indica- 
tive, in most cases, of the existence of melanotic tumors, it should 
be stated that this symptom cannot be regarded as pathognomonic, 
as it may be absent in the case of melanotic tumors, and present in 
wasting diseases and inflammatory affections, and may at times, 
though very rarely, even be associated with the presence of non-pig- 
mented growths. Nevertheless, its occurrence should always be 
regarded with suspicion, and, taken in conjunction with other symp- 
toms, will often lead to a correct diagnosis. 

Urines, which darken upon standing, should be subjected to the 
following tests : 

1. A few c.c. of urine are treated with bromine-water, when in the 
presence of melanin or melanogen a precipitate is obtained, which is 
yellow at first, but gradually turns black. 

2. The addition to melanotic urine of a few drops of a strong so- 
lution of perchloride of iron will cause the appearance of a gray 
color, which is imparted to the precipitate of phosphates occurring at 
the time, if more of the reagent is added, and which dissolves again 
in an excess. 

Phenol Urines. — The development of a dark brown or black color 
upon standing is not always due to the presence of melanin, as the 
same appearance may be noted in cases of poisoning with carbolic 
acid, following the ingestion of salol, hydrochinon, pyrocatechin, and 
salicylic acid, etc., in large amounts. The color in such cases is due, 
in all probability, to the presence of various oxidation-products of 
hydrochinon, and in the last instance possibly to the so-called humin- 
substances. 

The test referred to above will prevent any confusion as to the 
origin of the color noted, as far as melanin is concerned, and with the 
history of the case given, moreover, further chemical examination is 
generally unnecessary. In suspected cases of carbolic acid poison- 
ing, however, the mineral as well as the conjugate sulphates should 

be quantitatively determined, when the factor ~ (see Sulphates) will 

be found to be greatly diminished. If at the same time other factors, 
which might cause a greatly increased elimination of conjugate sul- 
phates, can be excluded, the diagnosis of poisoning with carbolic acid, 
or one of its derivaties, may be inferred. Salol and salicylic acid 
may be recognized from the fact that such urines, when treated with 
a solution of perchloride of iron, develop a marked violet color which 
does not disappear on standing. The reaction thus differs from that 
obtained with diacetic acid. See also p. 452. 



X 



THE CHEMISTRY OF THE URINE. 441 

Alkapton. — Urines are at times, though very rarely, seen, which 
like the phenol urines turn dark on standing, but in which the 
change in color is neither referable to the presence of phenol or its 
derivatives, nor to melanin. Such urines are of a normal color, 
when passed, but gradually turn a reddish-brown, upon exposure to 
the air. Treated with a small amount of an alkali, this change 
occurs almost immediately. Fehling's solution is reduced on the 
application of heat, while bismuth is not affected. Ammoniacal 
silver solution is reduced in the cold, and a temporary bluish-green 
color develops, when the urine is treated with a ferric salt. The 
fermentation test is negative, and examination with the polarimeter 
shows that the substance in question is not glucose. With phenyl- 
hydrazin no osazon is formed. 

Boedeker who first observed a urine of this kind termed the sub- 
stance giving rise to the reactions, just described, alkapton, and sub- 
sequently expressed the belief that his alkapton might possibly have 
been pyrocatechin. Subsequent investigators succeeded in isolating 
substances from such urines, which have been variously termed 
pyrocatechuic acid, urrhodinic acid, glycosuric acid, uroleucinic acid 
and uroxanthinic acid. Baumann and Wolkow finally were able to 
isolate homogentisinic acid in pure form from a urine of such a case, 
and expressed the belief that some of the substances obtained by 
previous observers were in reality the same. Since that time this 
acid has also been found by Ogden, Stange, Ewaldstier and others. 
There is reason to believe, however, that the reaction is not always 
due to one and the same substance. 

Of the origin of alkapton very little is known. Baumann ex- 
pressed the opinion that homogentisinic acid might be derived from 
ty rosin, and that the condition is referable to the activity of special 
micro-organisms in the upper portion of the intestines. Others 
oppose this view and regard alkaptonuria as evidence of a definite 
metabolic anomaly taking place in the tissues of the body. How- 
ever this may be alkaptonuria can scarcely be regarded as a patho- 
logic phenomenon, although it may occur in disease. It has thus 
been observed in connection with glycosuria, acute gastro-intestinal 
catarrh, phthisis, acute miliary tuberculosis, in one case of brain 
tumor, carcinoma of the prostate, etc. More frequently the condi- 
tion is accidentally discovered by the life insurance physician in ap- 
parently healthy individuals, and has repeatedly been confounded 
with glycosuria. Like cystinuria and diaminuria it may occur in 
families, appear in childhood already, and persist through many 
years and perhaps a life time. 

The amount of homogentisinic acid, which is eliminated in the 
twenty-four hours, is variable, but usually quite large. Baumann 
thus found an average elimination of 4.6 grammes, which, in one 



442 THE UBINE. 

case, could be increased to 14 grammes by the administration of 
tyrosin. Larger quantities are also obtained after a liberal inges- 
tion of meats. 

To isolate homogentisinic acid from alkapton urines, and to deter- 
mine its amount, Baumann's method may be employed. The col- 
lected amount of twenty-four hours is acidified with 250 c.c. of a 
12-per-cent. solution of sulphuric acid, and extracted three times 
with an equal volume of ether. The ethereal extract is evaporated 
to a syrup. The crystals, which separate out on standing, are dis- 
solved in 250 c.c. of water. This solution is brought near the boil- 
ing point, and is then treated with 30 c.c. of a neutral acetate of lead 
solution (1 : 5), and rapidly filtered. In the filtrate the lead salt 
crystallizes out in transparent needles and prisms. This is then de- 
composed Avith sulphuretted hydrogen and the filtrate carefully evap- 
orated on the water-bath, until the fluid begins to darken, when it is 
further concentrated in the vacuum to the point of crystallization. 
The resulting prismatic crystals are almost colorless and transparent. 
They melt at a temperature ofl46.5°-147° C, and are readily soluble 
in water, alcohol, and ether, and almost insoluble in chloroform, 
benzol, and toluol. A solution of the acid, which may thus be iso- 
lated in pure form, presents the same characteristics as the urine from 
which it was obtained. 

The following method, suggested by Garrod, may also be employed, 
and has the advantage of greater simplicity. 

The urine itself is heated nearly to boiling, without any preliminary 
treatment, and for every 100 c.c. of urine at least five or six grammes 
of solid neutral lead acetate are added. 

As soon as the acetate is dissolved, the bulky gray precipitate 
which forms is removed by filtration, and the filtrate, which has a 
pale yellow color, is allowed to stand for twenty-four hours in a cool 
place. If the urine be very rich in homogentisinic acid, or if the flask 
containing it be placed upon ice, minute acicular crystals, which are 
almost colorless, quickly begin to form, but as a rule crystallization 
does not commence until several hours have elapsed. The crystals 
are then much larger, are grouped in stars or rosettes, and are more 
deeply colored. 

In summer weather it would probably be desirable to start the 
crystallization by artificial cooling, but although at a low temperature 
the process is greatly accelerated, the final yield is not materially 
increased. 

If the formation of the crystals be long delayed the liquid may 
be again warmed, and some more lead acetate may be used. 

After the lapse of twenty-four hours no more crystals are formed, 
even when the liquid is allowed to stand upon ice. 

The crystalline product so obtained is lead homogentisinate. When 



PLATE XVI 



Ehrlieh's Diazo-Reaetion, as modified by the author. 
The orange color in the lower portion of the test tube may 
be obtained in any urine ; the dark carmine ring indicates 
the presence of the reaction in a well-pronouneed degree ; 
the colorless zone above is intended to indicate the am- 
monia that has been added. 



THE CHEMISTRY OF THE URINE. 443 

the crystals are dissolved in hot water the solution takes a deep brown 
color with alkalies, reduces Fehling's solution readily with the aid of 
heat, and yields a transitory deep blue color with a dilute solution of 
ferric chloride. From the lead salt free homogentisinic acid may 
be obtained by decomposing it with sulphuretted hydrogen. 

Blue Urines. — Blue urines are sometimes seen, the blue color of 
which is due to indigo formed from urinary indican, in all proba- 
bility within the urinary passages. Their occurrence can only be 
regarded as a medical curiosity. Formerly, when indigo was em- 
ployed in the treatment of epilepsy, blue urines were frequently 
seen. At the present time, where methylene blue is occasionally 
used in the treatment of malaria and chyluria, the pigment is found 
in the urine. 

Green Urines. — Green urines have also been described ; the cause 
of the color, however, has not been definitely ascertained. 

Pigments Referable to Drugs. — Certain drugs may also cause 
changes in the normal color of urine, and in doubtful cases inquiry 
in this direction should be made. It has been pointed out that car- 
bolic acid, hydrochinon, pyrocatechin, and salol cause the appearance 
of a dark-brown color, and that after the administration of indigo 
and methylene blue blue urines are voided. Santonin, rheum, and 
senna color urines a bright yellow, so that they may resemble icteric 
urines in appearance. The yellow color in such cases is changed to 
an intense red by the addition of an alkali, and, if ammoniacal fer- 
mentation is going on at the same time in the bladder, the patient may 
believe himself to be suffering from hematuria. The red color thus 
produced is due to the action of the alkali upon chrysophanic acid. 
When urines containing copaiba are treated with hydrochloric acid a 
red color results, which changes to violet upon the application of 
heat. During the administration of potassium iodide, or the use of 
iodine in any form, a dark mahogany color is obtained, when the 
urine is treated with nitric acid. In doubtful cases Stokvis' modifi- 
cation of Jaffe's test for indican should be employed, when in the 
presence of an iodide the chloroform assumes a beautiful rose-red 
color. 

For the detection of other drugs and poisons in the urine the 
reader is referred to special works. 

Ehrlich's Reaction. — Under certain pathologic conditions, and espe- 
cially in typhoid fever, a chromogen may be present in the urine, 
which, when treated with diazo-benzenc-sulphonic acid, and ammonia, 
imparts a distinct red color to the urine, varying from eosin to 
a deep garnet-red (Plate XVI.). This reaction, which is generally 
spoken of as Ehrlich's reaction, or the diazo-reaction, was at one 
time regarded as pathognomonic of typhoid fever. Subsequent ex- 
aminations, however, have shown that it may also be present in other 



444 THE URINE. 

diseases. Michaelis, who has made an exhaustive study of this ques- 
tion, divides the diseases, in which the reaction has been observed, into 
four groups. In the first group, comprising diseases of the nervous 
system, chronic diseases of the heart and kidneys, malignant tumors, 
etc., the reaction is rarely seen. When present it usually indicates a 
secondary infection. The second group includes those diseases, in 
which the reaction is almost always present, namely typhoid fever 
and measles. In the diseases of the third group it is often, though 
not invariably, observed. Under this group are classed scarlet fever, 
erysipelas, pneumonia, diphtheria, pyaemia, acute miliary tubercu- 
losis, etc. The fourth group finally comprises pulmonary tubercu- 
losis, and includes acute caseous pneumonia. 

The value of the reaction in typhoid fever was first over-esti- 
mated, but is at present certainly underestimated. I havepersonally 
studied this problem with great care, and after ten years' experience 
maintain, as I did eight years ago, that the test is a most important 
diagnostic aid in the disease in question. As a general rule the re- 
action is present as early as the fifth or sixth day and may persist 
into the third week ; it then disappears, but may reappear, when a 
relapse occurs. Excepting in children, its absence from the fifth to 
the ninth day usually indicates a mild case. This rule, however, is 
not without exception, and I have seen a case of typhoid fever, in 
which notwithstanding exceedingly high temperatures (106.5 at 6 
A. M.), the reaction was not obtained until the beginning of the 
third week, and then persisted only for a few days. When the re- 
action is continuously present after the third week I am inclined to 
suspect acute tuberculosis. 

Of late much attention has been paid to the occurrence of Ehrlich's 
reaction in pulmonary phthisis. As a result of his investigations 
Michaelis concludes that its presence in such cases either indicates, 
that the process is very extensive, or will progress very rapidly, and 
that the prognosis is grave. A cure, he thinks, is impossible, and 
improvement, if any, only temporary. His conclusions, in the main 
points, coincide with the results obtained by others, but it must be 
admitted that exceptions occur. Personally I regard the outlook as 
very bad in those cases, in which the reaction is almost constantly 
present, even if the physical signs are as yet but little pronounced. 

Of the nature of the body which gives rise to Ehrlich's reaction 
nothing is known, v. Jaksch regards the test as an uncertain indica- 
tion of the presence of acetone, but that this is not the case can be 
easily shown. 

As the preparation of chemically pure, crystalline diazo-com- 
pounds is a difficult process, Ehrlich uses sulphanilic acid, which, 
when treated with nitrous acid, in a nascent state, gives rise to the for- 
mation of diazo-benzene-sulphonic acid, as is shown by the equations : 



THE CHEMISTRY OF THE URINE. 445 

1 . NaN0 2 + HC1 = NaCl + HN0 2 
NH 2 N^ 

2. C 6 h/ 4-HN0 2 =C 6 H/ ^N + 2H 2 0. 

Para-amido- Diazo-benzene- 

benzene-sulphonic acid. sulphonic acid. 

This is the active principle in the mixture employed. 

Other compounds may, of course, also be used, such as meta-amido- 
benzene-sulphonic acid, ortho- and para-toluidin-sulphonic acid, etc. ; 
but of all these Ehrlich found the common sulphanilic acid the most 
convenient. Two solutions, which must be kept in separate bottles, 
are employed. The one is a 5-per-cent. solution of hydrochloric 
acid, to which sulphanilic acid is added in the proportion of 1 gramme 
for every 100 c.c. The other is an 0. 5-per-cent. solution of sodium 
nitrite. 

The two solutions are mixed, immediately before using, in the 
proportion of 40 to 1. A few cubic centimetres of urine are then 
treated with an equal volume of the reagent, the mixture is shaken 
and rendered alkaline with ammonium hydrate. This is best allowed 
to flow down the sides of the tube, so as to form a layer above the 
mixture. At the junction of the two fluids a colored ring will now 
be observed. With urines which do not contain the chromogen this 
will be a more or less distinct orange, while in its presence a red 
color is obtained. The intensity of this color may vary from eosin 
to a deep garnet-red. If the mixture is now agitated and the reac- 
tion is positive, the foam will likewise be colored red, and upon pour- 
ing the solution into a porcelain basin, containing much water, a 
beautiful salmon color is obtained, even if traces of the chromogen 
only are present. Carried out in this manner no question will arise 
as to the presence or absence of the reaction. Ehrlich states that on 
standing a green sediment is thrown down in the alkalinized mixture, 
and he regards this sediment as especially characteristic. My expe- 
rience has been that this occurs only when the color-reaction is well 
pronounced, and I am inclined to attach more importance to the 
salmon color obtained upon copious dilution. With normal urines 
this is never obtained, and it can still be seen when inspection of the 
fluid in the test-tube would leave in doubt. 

The older method of Ehrlich I have now abandoned, as the test 
just described is simpler and, in my experience, just as reliable. He 
advised the addition of about 50 c.c. of absolute alcohol to 10 c.c. of 
urine, subsequent filtration and examination of the filtrate, as just 
described. 

Greene states that if one part of the sodium nitrite solution is 
added to hundred instead of forty parts of the sulphanilic acid solution, 
a positive reaction is no longer obtained in cases of croupous pneu- 



446 THE URINE. 

inonia and of pulmonary tuberculosis, while in typhoid fever the re- 
action occurs with the same intensity. It is thus possible that the 
test may be still further modified, and become even more valuable. 

While in the absence of the chromogen, as I have already stated, 
a more or less pronounced orange color is usually obtained, certain 
exceptions have been noted. Ehrlich thus records that in urines, 
containing biliary coloring matter, an intensely dark, cloudy discol- 
oration occurs at times, which upon boiling, is changed to a well- 
marked reddish- violet. In rare instances of ulcerative endocarditis, 
hepatic abscess, and intermittent fever, Ehrlich further observed an 
intense yoke-yellow color, which was even imparted to the foam. In 
one instance, in which glycosuric acid apparently was present in the 
urine I obtained a dark brown color on standing, which ultimately 
turned to black. Of further interest is the observation of Burghart, 
that after the administration of tannic acid, gallic acid, and certain 
iodine preparations Ehrlich's reaction disappears from the urine. 
But as Burghart himself suggests it is likely that this inhibitory 
effect is not exerted upon the diazo-forming substance, but upon the 
reagent employed. 

Conjugate Sulphates. — In addition to indoxyl (see Indican), 
skatoxyl, phenol, paracresol, and pyrocatechin occur in the urine in 
combination with sulphuric acid. 

Skatoxyl. — Skatoxyl results from the skatol formed during the 
process of intestinal putrefaction, as indoxyl is derived from indol, 
and is partly eliminated in the urine as skatoxyl sulphate. Clinic- 
ally it is of little interest, as the amount excreted is very small, and 
it is not necessary to enter into a further consideration of its chem- 
ical properties or modes of detection at this place (see Feces). 

Phenol. — Phenol, according to Brieger, occurs only in very small 
amounts in human urine, the usual phenol reactions being largely 
referable to paracresol. Normally about 0.03 gramme is eliminated in 
the twenty-four hours, but in pathologic conditions much larger 
quantities may be found. Remembering the origin of phenol, it is 
clear that an increased elimination may be observed, whenever putre- 
factive processes are going on in the tissues and cavities of the body, 
or whenever there is an increase in the degree of intestinal putre- 
faction, though in the latter condition the indican is usually the only 
conjugate sulphate that is found increased. In peritonitis, diph- 
theria, erysipelas, scarlatina, empyema, pulmonary gangrene, putrid 
bronchitis, etc., an increased elimination of phenol is quite commonly 
seen. Important from a diagnostic standpoint, further, is the fact 
that in uncomplicated cases of typhoid fever no increase is observed, 
while this is common in tubercular meningitis. The largest amounts, 
of course, are seen in cases of poisoning with carbolic acid, or one of 
its derivatives. 



THE CHEMISTRY OF THE URINE. 447 

As the quantitative estimation of phenol is too complicated for the 
purposes of the general practitioner, Salkowski's qualitative test is 
here also described. From the intensity of the reaction certain con- 
clusions may be drawn as to the amount present. It is especially 
serviceable in cases of suspected poisoning with carbolic acid. 

Salkowski's Test for Phenol. — To this end about 10 c.c. of urine are 
boiled in a test-tube with a few cubic centimetres of nitric acid, and, 
on cooling, treated with bromine-water. The development of a pro- 
nounced turbidity, or the occurrence of a precipitate indicates the 
presence of an increased amount of phenol. 

Quantitative Estimation. — Principle : When potassium-phenyl 
sulphate is treated with hydrochloric acid, phenyl sulphate results, 
which further takes up one molecule of water, giving rise to the for- 
mation of sulphuric acid and phenol, according to the following 
equations : 

/>.C 6 H 5 ,O.C 6 H 5 

I. SO./ + HC1 = KC1 + S0 2 / 

\)K \)H 

O.C 6 H 5 OH 

II. SCX/ +H 2 0=:S0Z +C 6 H 5 .OH. 

^OH \)H 

From the action of bromine- water upon phenol a yellowish -white 
crystalline precipitate of tribromophenol results : 

C 6 H 5 .OH + 6Br = 3HBr + C 6 H 2 Br 3 .OH. 

As 331 (molecular weight) parts by weight of tribromophenol 
correspond to 94 (molecular weight) parts by weight of phenol, the 
amount of the latter contained in a certain volume of urine is readily 
determined according to the equation : 

331 : 94 : : x : y, and y = £* = 0.28398 x, 

in which x indicates the weight of the tribromophenol, found in the 
amount of the urine employed, and y the corresponding quantity of 
phenol. 

Method. — 500-1,000 c.c. of urine are treated with one-fifth of 
this amount of dilute hydrochloric acid (1 : 4), and distilled so long 
as a specimen of the distillate is rendered cloudy by the addition of 
bromine-water (1 : 30), the specimens used for this purpose being 
carefully preserved. The total quantity of the filtered distillate, 
together with the specimens which have been set aside, is now 
treated with bromine water, shaking the mixture after each addition 
of the reagent, until a permanent yellow color results. Beyond this 
point a further addition is beset with danger, as compounds will be 



448 THE VRINE. 

formed which contain more bromine, the presence of which would 
indicate a smaller amount of phenol than that actually contained in 
the urine. After two or three days the precipitate is collected on a 
filter, which has been dried over sulphuric acid, washed with water 
containing a trace of bromine, and then dried over sulphuric acid and 
weighed. 

Pyrocatechin. — Urines containing pyrocatechin, like those con- 
taining hydrochinon (see above), darken upon standing, though pre- 
senting a normal color, when voided. 

Acetone. 

The amount of acetone which may be found in the urine under 
normal conditions varies between 0.008 and 0.027 gramme, and is 
greatly influenced by the character of the diet. Whenever the carbo- 
hydrates are withdrawn the quantity rapidly increases, and reaches 
its maximum about the seventh or eighth day. At this time from 
200 to 700 mgrms. may be eliminated in the twenty-four hours. 
If, then, carbohydrates are again added to the. diet the acetonuria 
soon disappears. This result is not reached, however, if fats are sub- 
stituted for the carbohydrates. The acetonuria is greatest when but 
little albuminous food and no carbohydrates at all are ingested, and 
during starvation the same amounts are essentially found. There 
can hence be no doubt that acetone is derived from proteid material, 
be this in the form of organized or circulating albumin. Increased 
amounts are accordingly found whenever, as in fevers, the various 
cachexias, in conditions associated with inanition, etc., large quantities 
of circulating albumin are broken down, or whenever carbohydrates 
are not furnished in sufficient amount. 

Most important is the diabetic form of acetonuria, and it may be 
stated, as a general rule, that the diagnosis of diabetes mellitus is justi- 
fiable, whenever sugar and notable quantities of acetone are found in 
the urine. The amount of acetone, moreover, stands in a direct 
relation to the intensity of the disease, the maximum excretion being 
usually observed toward the fatal end. Whether or not this form of 
acetonuria can always be explained upon the basis given above must 
still remain an open question. There can be no doubt, however, that 
the threatening symptoms w-hich are so commonly associated with a 
greatly increased elimination of acetone, will often disappear when 
carbohydrates are administered in large amounts. It is certain, 
moreover, that diabetic coma is more apt to occur when the old- 
fashioned plan of excluding carbohydrates entirely from the dietary 
of diabetic patients is adopted. Hirschfeld suggests that in every 
case of diabetes the excretion of acetone be carefully followed, and 
that large amounts of carhohydrates are administered whenever the 



THE CHEMISTRY OF THE URINE. 449 

acetonuria approaches a dangerous height. With his experience my 
own agrees. 

Among the febrile diseases in which acetonuria has been observed 
may be mentioned typhoid fever, pneumonia, scarlatina, measles, 
acute miliary tuberculosis, acute articular rheumatism, and septi- 
caemia. In those of short duration, on the other hand, even if the 
fever is high, as in acute tonsillitis, intermittent fever, the hectic 
fever of phthisis, etc., an increased elimination of acetone is rarely 
observed. In the continued fevers the acetonuria is largely referable 
to* the character of the diet, as carbohydrates are usually excluded 
entirely, and I have repeatedly observed that a return to the normal 
occurred, as soon as sugar was administered in amounts varying from 
50 to 100 grammes. 

In certain nervous and mental diseases, as in general paresis, mel- 
ancholia, following epileptic seizures, and in tabes, acetonuria is fre- 
quently observed. During the second stage of general paresis in- 
creased amounts are indeed quite constantly found, but Hirschfeld is 
probably correct when he states that the psychotic form of acetonuria 
is largely referable to improper feeding. 

In the primary diseases of the stomach, and notably in carcinoma, 
acetonuria is frequently observed, and it is possible that the ace- 
tone in these cases is to some extent, at least, formed in that organ 
directly from the proteids ingested. The fact that in carcinoma 
acetone may be observed at a time when marked loss of flesh has not 
as yet occurred, and that larger amounts of acetone may be found in 
the stomach than in the urine, is certainly in favor of this view. 

The acetonuria following chloroform narcosis is probably referable 
to an increased destruction of organized albumin. Finally, the pos- 
sibility of the occurrence of an enterogenic form of acetonuria must 
be borne in mind. The cases of so-called asthma acetonicum prob- 
ably belong to this class. 

Tests for Acetone. — Legates Test. — This test may be applied 
to the freshly voided urine, but is not conclusive. Several c.c. of 
urine are treated with a few drops of a strong solution of sodium- 
nitro-prusside and sodium hydrate, when the mixture will present a 
red color, which rapidly disappears, and in the presence of acetone is 
replaced by a purple or violet-red when acetic acid is added. As a 
rule, it is safer to distil the urine (500-1,000 c.c), after the addition 
of a little phosphoric acid (1 gramme pro litre), and to employ the 
first 10-30 c.c. of the distillate for the following two tests. 

Lieben's Test. — A few c.c. of the distillate are treated with 
several drops of a dilute solution of iodo-potassic iodide and sodium 
hydrate, when in the presence, even, of traces of acetone a precipita- 
tion of iodoform in crystalline form occurs, which may be readily 
recognized by its odor when the solution is heated. 
29 



450 THE URINE. 

Reynold's Test. — A few c.c. of the distillate are treated with a 
small amount of freshly precipitated yellow oxide of mercury. This 
is prepared by precipitating a solution of bichloride of mercury with 
an alcoholic solution of sodium hydrate. If acetone is present, a 
black color, due to the formation of sulphide of mercury, will result 
in the clear nitrate upon the addition of a few drops of ammonium 
sulphide. 

Denniges' Test, as Modified by Oppenheimer. — The re- 
agent is prepared as follows : 20 grammes of concentrated sulphuric 
acid are poured into 100 c.c. of distilled water, when 5 grammes of 
freshly prepared yellow oxide of mercury (see Reynold's test) are 
added. The mixture is allowed to stand for twenty-four hours and 
is then ready for use. 

This reagent is added to about 3 c.c. of urine, drop by drop, until 
the precipitate, which is thus formed, no longer disappears on stir- 
ring. When this point is reached a few more drops are added. 
After 2-3 minutes the precipitate is filtered off. The clear filtrate 
is further treated with about 2 c.c. of the reagent, and 3-4 c.c. of a 
30-per-cent. solution of sulphuric acid, and boiled for a minute or 
two, or still better, placed in a vessel with boiling water. In the 
presence of an abundant amount of acetone, a heavy white precipi- 
tate forms immediately, while in the presence of traces only (less 
than 1 : 50000), a slight cloud develops on standing for several min- 
utes. The precipitate is almost entirely soluble in an excess of hy- 
drochloric acid. 

If albumin is present, the urine becomes turbid at once, when the 
reagent is added. In that case the test is continued as described, at- 
tention being directed to the coarser precipitate which occurs later. 
In such urines large amounts of the reagent must be added, the idea 
being to precipitate everything that can be precipitated with the re- 
agent, before heating. 

It will be observed that Denniges' test is much simpler than the 
tests already described, and Oppenheimer claims that it is as delicate 
as that of Lieben, vis, giving a w T ell-pronounced reaction with a 
dilution of 1 : 20000, and being still discernible with a dilution of 
1 : 60000. As diacetic acid yields acetone, when treated with mineral 
acids, a positive result is always obtained when this is present. But 
as diacetic acid is usually only found in association with acetone, 
this fact does not lessen the value of the test, and is an error, more- 
over, which is common to the other tests as well. 

Quantitative Estimation of Acetone. — For the purpose of 
estimating the amount of acetone the method of Messinger, as modi- 
fied by Huppert, is now employed, and greatly to be preferred to the 
older procedure of v. Jaksch. 

Principle : It is based upon the observation of Lieben that acetone 



THE CHEMISTRY OF THE URINE. 451 

gives rise to the formation of iodoform when treated in an alkaline 
solution with iodine. If, then/a solution of acetone is treated with a 
known amount of iodine, it is a simple matter to determine the quan- 
tity present by retitrating the iodine which was not used in the for- 
mation of iodoform. 
Solutions required : 

1. Acetic acid (50-per-cent. solution). 

2. Sulphuric acid (12-per-cent. solution). 

3. Sodium hydrate solution (50 per cent.). 

4. A decinormal solution of iodine. 

5. A decinormal solution of sodium thiosulphate. 

6. Starch solution (see p. 174). 
Preparation of the solutions : 

1 . The decinormal solution of iodine is prepared as described else- 
where (see p. 173). 

2. As the molecular weight of sodium thiosulphate — Na^Og + 
5H 2 — is 248, a decinormal solution of the salt would contain 24.8 
grammes to the litre. This quantity is dissolved in about 950 c.c. 
of distilled water, and brought to the proper strength by titration 
w T ith a decinormal solution of iodine. As 1 c.c. of the thiosulphate 
solution should correspond to 1 c.c. of the iodine solution, the neces- 
sary amount of water which must be added to the former is then de- 
termined. 

Method : One hundred c.c. of urine, or less, if much acetone is 
present, as determined by Legal 's test, are treated with 2 c.c. of the 
acetic-acid solution and distilled, until seven-eighths of the total 
amount have passed over. The distillate is received in a retort 
which is connected with a ball arrangement filled with water. As 
soon as seven-eighths of the urine have been distilled over, a small 
amount of the distillate of the remainder is tested for acetone accord- 
ing to Lieben's method. Should a positive reaction be obtained, it 
will be necessary either to repeat the entire process with less urine, 
diluted to about 200 c.c, or to add about 100 c.c. of water to the 
residue and to distill until all the acetone has been driven over. The 
distillate is then treated with 1 c.c. of the sulphuric acid and redis- 
tilled. The addition of the acetic acid and of the sulphuric acid, re- 
spectively, serves the purpose of holding back the phenol and the 
ammonia. Should the first distillate contain nitrous acid, moreover, 
which may be recognized by the addition of a little starch paste con- 
tinuing a trace of potassium iodide, when the solution will turn blue, 
this is removed by adding a little urea. The second distillate is re- 
ceived in a bottle provided with a well-ground glass stopper, and 
holding about one litre. To prevent the escape of acetone, the glass 
stopper is replaced by a doubly perforated cork, through which two 
glass tubes pass, one to the distilling apparatus, the other to a ball 



452 THE URINE. 

arrangement, as described above. The distillate is then treated with 
a carefully measured quantity of the one-tenth normal solution of 
iodine, — about 10 c.c. for 100 c.c. of urine, — and solium hydrate so- 
lution, until the iodoform separates out. To this end a slight excess 
of the solution must be added. Should ammonia be present, a 
blackish cloud will be observed at the zone of contact of the sodium 
hydrate and the iodine solution, and it will be necessary to repeat 
the entire process. The bottle is closed and shaken for about one 
minute. The solution is then acidified with concentrated hydro- 
chloric acid, when the mixture assumes a brown color if iodine is 
present in excess. If this does not occur, more of the iodine solu- 
tion must be added, and the process repeated until an excess is pres- 
ent. The excess is then retitrated with the thiosulphate solution, 
until the fluid presents a faint-yellow color. A few c.c. of starch solu- 
tion are now added ; the titration is then continued until the last 
trace of blue has disappeared. The number of c.c. employed in the 
titration is finally deducted from the total amount of the iodine solu- 
tion added, and the result multiplied with 0.967. The figure thus 
obtained will then indicate the amount of acetone contained in the 
100 c.c. of urine, in mgrms., as 1 c.c. of the thiosulphate solution is 
equivalent to 1 c.c. of the iodine solution, or to 0.967 mgrm. of ace- 
tone. 

Diacetic Acid. 

The occurrence of diacetic acid in the urine must always be re- 
garded as abnormal. Its pathologic significance is identical with that 
of acetonuria. It is met with especially in diabetes, in various diges- 
tive diseases, and in febrile diseases. In the high and continued 
fevers of childhood it is almost constantly present. 

In order to demonstrate the presence of diacetic acid a few c.c. of 
urine are treated with a strong solution of perchloride of iron, added 
drop by drop. Should a precipitation of phosphates occur, these are 
filtered off, when more of the iron solution is added to the filtrate. 
If now a Bordeaux-red color appears, another portion of the urine 
is boiled and similarly treated. If in the second test no reaction is 
obtained, a third portion of the urine is treated with sulphuric acid 
and extracted with ether. A positive reaction, when the ethereal 
extract is tested with perchloride of iron, the color disappearing 
upon standing for twenty-four to forty-eight hours, will indicate the 
presence of diacetic acid, particularly if the urine is also rich in acetone. 

Arnold's Test. — Two solutions are employed, viz, a solution of 
paramido-aceto-phenon, and a one-per-cent. solution of sodium 
nitrite. The first is prepared by dissolving one gramme of para- 
mido-aceto-phenon in from 80-100 c.c. of distilled water, and add- 
ing hydrochloric acid, drop by drop, until the solution, which at 
first is yellow, becomes perfectly colorless ; an excess, however, 



THE CHEMISTRY OF THE URINE. 453 

should be avoided. Immediately before using, the two solutions are 
mixed in the proportion of two to one. A few cubic centimetres of 
the reagent a?e then treated with an equal volume of urine, when a 
few drops of ammonia are added. Thus treated, all urines give a 
more or less marked brownish-red color on agitation, and if much 
diacetic acid is present, an amorphous reddish-brown sediment is 
thrown down. A small amount of the colored solution is then 
placed in a conical glass and treated with an excess of concentrated 
hydrochloric acid (10-12 c.c. for every 1 c.c). In the presence of 
diacetic acid the mixture assumes a beautiful purplish-violet color. 
According to Arnold, the test is more delicate than that of Ger- 
hardt, and does not respond with acetone or oxy-butyric acid. With 
bilirubin and the common antipyretics, as well as salicylic acid, no 
reaction is obtained. Highly colored urines should first be filtered 
through animal charcoal. 

Oxybutyric Acid. 

The fact that in some cases of diabetes an excessive elimination of 
ammonia was observed, led to the belief that there must be present an 
unknown acid ; this was shown to be /9-oxybutyric acid. The occur- 
rence of this acid in the urine of diabetic patients is of great clinical 
interest, as a probable connection has been established between its 
presence in the blood and diabetic coma. The latter condition is 
explained by assuming that the diabetic patient is unable to furnish 
sufficient quantities of ammonia to neutralize the acids formed in the 
tissues of the body, the alkalies of the blood being consequently at- 
tacked. A prophylactic treatment with alkalies, such as intravenous 
injections, has hence been suggested in severe cases. This, however, 
is a mere theory, and the fact that a case of diabetic coma has been 
reported in which the alkalinity of the blood was not diminished, 
and in which recovery took place without the use of alkalies, renders 
the correctness of the hypothesis rather doubtful. Possibly the cause 
of the coma is due to the presence of toxins circulating in the blood, 
which cause an increased tissue-destruction, with a simultaneous 
formation of acetone and abnormal acids. 

The presence of oxybutyric acid may always be regarded as indi- 
cating a severe type of the disease, and when associated with marked 
acetonuria and diaceturia as indicating danger of coma. 

The presence of oxybutyric acid may be inferred in diabetic 
urines, if after fermentation a rotation of the plane of polarized 
light to the left is observed. 

Lactic Acid. 

Sarco-lactic acid is normally absent from the urine, but is met with 
in pathologic conditions, and particularly in hepatic diseases, as the 



454 THE URINE. 

liver is normally concerned in the decomposition of lactic acid and 
of the lactates that have been ingested with the food. 

In order to test for lactic acid the urine is evaporated on a water- 
bath to a thick syrup and extracted with 95-per-cent. alcohol. This 
is decanted off after twenty-four hours, evaporated to a syrup, acidi- 
fied with dilute sulphuric acid, and extracted with ether so long as 
this presents an acid reaction. The ether is then distilled off, and 
the residue dissolved in water. This solution is treated with a few 
drops of a solution of basic acetate of lead, filtered, the excess of 
lead removed by means of sulphuretted hydrogen, and the filtrate 
evaporated to dryness on the water-bath, when the lactic acid will 
remain behind as a slightly yellowish syrup. This is then dissolved 
in a little water, the solution saturated with zinc carbonate, and heat 
applied. Zinc lactate will separate out upon evaporation, and may 
be recognized by the form of its crystals, viz, small prisms. 

Volatile Fatty Acids. 

The term lipaddurid has been applied to an increased elimination 
of volatile fatty acids in the urine, and may be observed in various 
hepatic diseases affecting the proper structure of the liver, in leu- 
kaemia, in diabetes, in purulent peritonitis, phlegmonous tonsillitis, 
erysipelas, etc. Traces of fatty acids are also found under normal 
conditions, and are probably formed in the lower segment of the 
small intestine. The fatty acids which have thus far been isolated 
from the urine are formic, acetic, butyric, and propionic acid. They 
may be demonstrated in the same manner as described in the chapter 
on Feces. According to some observers the amount of fatty acids in 
the urine may be regarded as an index of the degree of carbohydrate 
fermentation in the intestinal tract. Under normal conditions this 
may be the case, but in disease the question is probably more com- 
plicated. 

Fat. 

Under strictly normal conditions the urine contains no fat, while 
variable amounts may be found in disease. When present in large 
quantities, so that it is possible to recognize it with the naked eye, 
the condition is termed lipuria. Such cases, however, are rare, and 
the diagnosis should only be made, when it is possible to exclude an 
accidental contamination of the urine. Smaller quantities of fat, 
recognizable only with the microscope, are much more common, and 
are indeed quite constantly observed, whenever fatty degeneration of 
the renal epithelial cells, of pus-corpuscles, or of tumor-particles is 
taking place in the urinary tract. The fat-droplets may then be found 
floating in the urine, or attached to, or imbedded in any morphologic 
elements that may be present. Lipuria may also occur when ab- 



THE CHEMISTRY OF THE URINE. 455 

normally large quantities of fat are circulating in the blood. It is 
thus observed after the administration of cod-Iiyer oil in large quan- 
tities, following oil inunctions, in cases of fracture of the long bones 
with extensive destruction of the bone-marrow, in cases of eclampsia, 
as also in such diseases as diabetes mellitus, chronic alcoholism, 
phthisis, obesity, leukaemia, in certain mental diseases, in affections 
of the pancreas and heart, etc. 

The term chyluria or galacturia has been applied to a condition in 
which a turbid urine presenting the macroscopic appearance of milk 
is excreted. Upon microscopic examination it may be demonstrated 
that the turbidity in such cases is owing to the presence of innumer- 
able, highly refractive globules of fat, which may be removed by 
shaking with ether. Of morphologic constituents leucocytes are 
occasionally encountered in large numbers. Red blood-corpuscles 
are also seen at times, and when present in large numbers impart a 
rose-color to the urine. Fibrinous coagula are often observed when 
the urine has stood for some time, and the entire bulk of urine may 
even become transformed into a gelatinous mass. Albumin is pres- 
ent in most cases in the absence of other constituents pointing to 
renal disease, such as tube-casts and renal epithelial cells. Leucin, 
tyrosin, and cholesterin may also at times be found, and particularly 
the latter. It was formerly quite generally accepted that this condi- 
tion was due to the presence of the filaria sanguinis hominis ; but 
while filarise are undoubtedly present in the blood in the majority of 
instances, and may also be present in the urine, it has been demon- 
strated that cases occur in which filariasis does not exist, and Gotze 
expressed the opinion that chyluria may be owing to a distinct ana- 
tomical lesion affecting the renal parenchyma. Further observations, 
however, are necessary, in order to clear up not only the etiology of 
the disease, but also the manner in which the fat and albumin enter 
the urine. 

Ferments. 

Ferments may be demonstrated in every urine, both under physi- 
ologic and pathologic conditions, but are of little clinical impor- 
tance, excepting, perhaps, pepsin, which is said to be absent in cases 
of typhoid fever, carcinoma of the stomach, and possibly also in 
nephritis. In order to demonstrate its presence a small flake of 
fibrin is placed in the urine, and after several hours removed to a 12- 
to 3-p.-m. solution of hydrochloric acid. The pepsin, if present, 
will have become deposited upon the fibrin, and cause the digestion 
of the latter in the hydrochloric-acid solution. Diastase, a milk- 
curdling ferment, and one causing the decomposition of urea into 
carbon dioxide and ammonia have also been observed. 



456 THE URINE. 

Gases. 

Every urine contains a small amount of gases, notably carbon 
dioxide, oxygen, and nitrogen, which may be withdrawn by means 
of an air-pump. 

Under pathologic conditions sulphuretted hydrogen is at times 
also found, constituting the condition known as hydrothionuria. In 
some instances this is referable to a diffusion of the gas into the blad- 
der from neighboring organs, or accumulations of pus ; but this is 
rare. 

In others an abscess has ruptured into the bladder, or a direct 
communication exists between it and the bowel. Under such con- 
ditions it can, of course, not be surprising that sulphuretted hydro- 
gen together with other products of albuminous putrefaction are 
eliminated in the urine. More commonly, however, the hydro- 
thionuria occurs idiopathically, and is then referable to the action of 
certain micro-organisms. This can be readily demonstrated by add- 
ing a few cubic centimetres of such urine to normal urine, w 7 hen upon 
standing the formation of sulphuretted hydrogen may be demon- 
strated in the normal specimen. The usual organisms, however, 
which cause ammoniacal decomposition, apparently play no part in 
this process, and the formation of the sulphuretted hydrogen may be 
observed before ammoniacal decomposition has set in, and while the 
reaction is yet acid. If a small amount of ordinary decomposing 
urine, moreover, is added to fresh normal urine no sulphuretted 
hydrogen is as a rule produced. The character of the organisms 
in question is variable ; sometimes micrococci are found, at other 
times bacilli and in still other instances both. Besides being capable 
of producing sulphuretted hydrogen from the sulphur bodies of the 
urine, some of them will also cause the formation of ammonium car- 
bonate in dilute solutions of urea. 

The source of the sulphuretted hydrogen in cases of hydrothionuria 
is in most cases probably the so-called neutral sulphur, but it is pos- 
sible that the oxidized sulphur is at times also attacked. Very inter- 
esting is the fact that in cystinuria, where the neutral sulphur is 
more or less increased, hydrothionuria is quite commonly observed. 
Its occurrence in such cases is indeed so frequent that I am inclined 
to suspect cystinuria, although crystals of cystin are not found in 
the sediment. Further work in this direction, however, is needed, 
and especially to determine the relative frequency with which the 
two conditions are associated. 

In a few instances, which have been recorded, the hydrothionuria 
accompanied indigosuria, viz, the presence of free indigo-blue in the 
urine, and this Midler has likewise shown to be referable to the 
action of certain micro-organisms. One case of this kind I saw 
several years ago, but made no examination for the presence of cystin. 



THE CHEMISTRY OF THE URINE. 457 

Owing to the well-known poisonous effect of sulphuretted hydro- 
gen upon the blood, it is well in every case to ascertain whether its 
formation occurs in the bladder already, or whether it only takes 
place on standing. The formation of sulphuretted hydrogen in de- 
composing urines, containing albumin, is of course a common event 
and should not be confused with the idiopathic hydrothionuria here 
described. 

The chemical test for sulphuretted hydrogen is very simple : A 
strip of filter paper is moistened with a few drops of sodium hydrate 
and lead-acetate solution and clamped into the neck of the bottle 
containing the urine. After a variable length of time, in some in- 
stances immediately, in others only after 12-24 hours a discoloration 
of the paper will be observed, varying from a grayish-brown to 
black, according to the amount present. When this is large it is of 
course also recognized by its characteristic odor. 

Ptomains. 

Numerous researches have shown that traces of toxic alka- 
loidal substances may be encountered in the urine under the most 
diverse pathologic conditions, and may even be present in health. 
Of the true nature of these bodies, however, but little is known. 
Thudichum claims to have isolated three distinct basic substances 
from normal urine, which he has termed reducin, parareducin and 
aromin. Pouchet and Mme. Eliacbeff, working in Gautier's labora- 
tory, have likewise extracted toxic bodies from normal urines, and 
Adduco states that after fatiguing exercise, especially, he could 
demonstrate a substance in the urine, which w T as extremely toxic, 
and not identical with cholin, as was first supposed. All this work, 
however, must be gone over again with great care, before the results 
obtained can be regarded as conclusive. This is also true of the 
work which has been done in various diseases. Some observers have 
here described bodies which they regard as specific toxins. Griffith 
thus reports the presence of a specific poison of scarlatina, of measles, 
mumps, etc. Others again have only obtained negative results. 

The only substances belonging to the class of ptomains, which 
have thus far been obtained from the urine in amounts sufficient to 
establish their identity, are cadaverin and putrescin. They were 
originally discovered by Brieger in putrefying cadavers, and subse- 
quently also found in cultures of the bacillus of Asiatic cholera, the 
Finkler-Prior bacillus of cholerina, the bacillus of tetanus and in the 
rice-water stools of cholera patients. From the urine cadaverin, 
putrescin and a third diamin, isomeric with cadaverin, and which 
has been regarded as saprin or neuridin, were first obtained by Bau- 
mann and v. Udranszky in a ease oi' oystinuria, and thus tar dia- 
minuria appears to occur only in association with this disease. All 



458 THE URINE. 

attempts to isolate diamins from the urine under other pathologic con- 
ditions, at least, have given rise to negative results. Whether or not 
diaminuria is invariably associated with cystinuria is, however, an 
open question. Putrescin has not again been seen, while Brieger, Stadt- 
hagen,Leo,Garrod, Lewis, and I have succeeded in isolating cadaverin 
from such urines. Others have been less successful, and the theory 
which was announced shortly after Baumann's discovery, and quite 
generally accepted, namely, that the formation of the diamins in 
question, is in some manner responsible for the appearance of cystin 
in the urine, was certainly premature. This is even more true of 
the inference drawn from this supposed association, viz, that cysti- 
nuria is a specific infectious disease of the intestinal canal. This 
conclusion was based upon the belief that diamins are only formed 
from albuminous material in the presence of certain bacteria. I have 
shown, however, that this is not necessarily the case, and that putres- 
cin, at least, may be formed in the absence of any micro-organisms. 
Further investigation will show whether or not cystinuria is invari- 
ably accompanied by diaminuria. Personally I incline toward the 
belief that this is the case, but I have also shown that while cysti- 
nuria and diaminuria may coexist, this is not always so, and that 
the two conditions may alternate, and that the one may temporarily 
disappear, while the other continues. Like Moreigne, I have been 
led to the conclusion that diaminuria is a metabolic anomaly, an- 
alogous to diabetes and gout, and that both diaminuria and cystinuria 
are the expression of a marked deficiency of the normal oxidation 
processes of the body. 

The amount of diamins, which may be met with in the urine of 
cystinuric patients is extremely variable. In my own case I have on 
one occasion been able to isolate as much as 1.6 grammes of the ben- 
zoylated cadaverin from the collected amount of twenty-four hours. 1 
On other days traces only were present, and at times, as I have 
already stated, no diamins at all could be found. A few observers 
who have investigated this question, state that they were unable to 
find even traces of diamins in their cases, but as single examinations 
only were made, their conclusion, that diaminuria does not always 
accompany cystinuria is scarcely justifiable. When single negative 
results are obtained, the examination should be repeated at frequent 
intervals, or larger quantities of urine employed. In general, I 
should advise those who wish to investigate the question of ptoma- 
inuria to experiment with large quantities of urine only, as some of 
the bodies belonging to this order exhibit a degree of toxicity which 
is out of all proportion to the amount present. Where specific alka- 
loids are to be sought for, it is scarcely worth while to use less than 

1 In the case of Dr. Lewis, which was examined in my laboratory, 0.3 gramme 
only could be obtained from 12,000 c.c. 



THE CHEMISTRY OF THE URINE. 459 

100 or 200 litres of urine, and even with such amounts the results 
are frequently cliappointing. In cases of cystinuria much smaller 
quantities will usually suffice, and an initial experiment may be made 
with the collected urine of twenty-four hours. 

To examine into the presence of diamins the following method may 
be employed : 

Method of Baumann and v. Udranszky. — The collected 
urine of at least twenty-four hours is shaken with a 10-per-cent. so- 
lution of sodium hydrate and benzoyl chloride in the proportion of 
1,500 : 200 : 25, until the odor of the benzoyl chloride has entirely 
disappeared. The resulting precipitate contains phosphates, the ben- 
zoyl compounds of the normal carbohydrates of the urine and a por- 
tion of the benzoylated diamins. These are filtered off with the aid 
of a suction pump and digested with alcohol. The filtered alcoholic 
extract is then concentrated to a small volume and poured into about 
30 times its amount of water. Upon standing for from twelve to 
forty-eight hours, the benzoylated diamins separate out in the milky 
fluid in the form of a more or less voluminous sediment, composed 
of fine, intensely white crystals. In order to remove the benzoy- 
lated carbohydrates, which are likewise present, the precipitate is 
redissolved in alcohol, the solution concentrated to a small volume 
and diluted with water, as described. This process is repeated sev- 
eral times. The resulting crystals, if both diamins are present, will 
loose their water of crystallization at 120° C. and melt at 140° C. 

A smaller portion of the benzoyl diamins remains in the first fil- 
trate. In order to recover this, the filtrate is acidified with sul- 
phuric acid, and extracted with ether. The ethereal residue, before 
congealing, is placed in as much of a 12-per-cent. solution of sodium 
hydrate as is required for its neutralization, when from 3-4 times 
the volume of the same solution is further added. This mixture is 
placed in the cold, when long needles and platelets separate out, 
which consist of the sodium compound of benzoyl cystin and the 
benzoylated diamins. The sediment is filtered off and placed in cold 
water, in Avhich the sodium benzoyl cystin dissolves, while the ben- 
zoyl diamins remain. 

In order to separate the putrescin from the cadaverin, the crystals 
are dissolved in a little warm alcohol and treated with 20 times the 
volume of ether. Benzoyl-putrescin is thus thrown down and may 
be recognized from its melting point, viz, 175°-17()° C, while the 
ethereal residue contains the benzoyl-cadaverin, which melts at from 
129°-130° C. 

The diamins may then be separated from the benzoyl radicle by 
heating the crystals on the water bath with a mixture of equal parts 
of alcohol and concentrated hydrochloric acid, until a specimen is 
entirely dissolved by sodium hydrate. The separation is complete 



460 THE URINE. 

after from 24 to 48 hours, according to the amount present. The 
solution is then diluted with water, when the benzoic acid, which has 
been formed, separates out and is filtered off. After extracting with 
ether, in order to remove any benzoic acid still remaining, the filtrate 
is evaporated to dryness. A crystalline mass remains, which is easily 
soluble in water and with difficulty so in alcohol. This consists of 
putrescin- and cadaverin-hydrochlorate, from which the various 
double salts with platinum, silver, mercury, etc., can be readily ob- 
tained. The platinum salt of cadaverin is thus formed by adding an 
alcoholic solution of platinum 'chloride to the solution of the hydro- 
chlorate in alcohol, as a voluminous yellow crystalline mass, which 
can be purified by recrystallization from hot water. When this salt 
is decomposed with sulphuretted hydrogen the hydrochlorate again 
results, from which the pure base is obtained by distillation with 
caustic potash. During this distillation water at first passes over, 
and above 160° C. a colorless oil, the boiling point of which is about 
173° C. This constitutes the free base, which may be further recog- 
nized by its sperm-like odor and the avidity with which it attracts 
carbon dioxide from the air, to form a carbonate. 



MICROSCOPIC EXAMINATION OF THE URINE. 

Sediments. 

In the chapter treating of the general physical characteristics of 
the urine it was stated that, on standing, every urine gradually be- 
comes cloudy, owing to the development of the so-called nubecula. 
This was shown to consist of a few mucous corpuscles, some pave- 
ment epithelial cells, derived from the urinary and genital passages, 
and under certain conditions of a few crystals of uric acid, of oxalate 
of calcium, or both. It was further pointed out that owing to a 
diminution in the acidity of the urine on standing, in consequence 
of an interaction between the neutral urate of sodium and the acid 
phosphate of sodium, a sediment is thrown down which consists of 
acid urate of sodium, and at times of free uric acid (see Reaction). 
Should the reaction of the urine upon being voided be alkaline, how- 
ever, a condition which may occur physiologically, when it is depen- 
dent upon the ingestion of large quantities of vegetables rich in 
organic salts of the alkalies, but which may also be due to ammo- 
niacal fermentation, those constituents of the urine which are held 
in solution merely in consequence of the presence of acid sodium 
phosphate are also thrown down. In that case the sediment consists 
essentially of calcium, magnesium, and ammonium salts. Crystals 
of ammonio-magnesium phosphate, it is true, may also be observed 
in alkaline urines of the first variety, but are then almost always due 



MICROSCOPIC EXAMINATION OF THE URINE. 461 

to an increased elimination of ammonia, and hence rarely observed 
in physiologic conditions. 

Normally calcium is found only in combination with phosphoric 
acid and carbonic acid. Of the three possible calcium salts of phos- 
phoric acid, — i. e., Ca 3 (POJ 2 , CaHP0 4 , and Ca(H a P0 4 ) 3 , — only the 
former two are found in an alkaline urine, but may also be observed 
in specimens which are either neutral or at least but faintly acid. 
The acid calcium phosphate, Ca(H 2 P0 4 ) 2 , is seen but rarely in sedi- 
ments, and its occurrence always presupposes the existence of a high 
degree of acidity, being precipitated together with uric acid, and 
under similar conditions. Calcium carbonate, 0aCO 3 , is seen only 
in neutral or alkaline urines. As soon as ammoniacal fermentation 
has begun, ammonium salts are, of course, formed, viz, ammonium 
urate and ammonio-magnesium phosphate. 

The following table shows the various mineral constituents which 
are usually observed in sediments, the reaction of the urine being in 
every case the all-important factor : 
Reaction acid. 

Uric acid. 

Urate of sodium. 

Oxalate of calcium. 

Primary calcium phosphate. 

Ammonio-magnesium phosphate. 
Reaction alkaline (referable to fixed alkalies). 

Secondary calcium phosphate. 

Tricalcium phosphate. 

Calcium carbonate. 

Ammonio-magnesium phosphate. 
Reaction alkaline (referable to ammonia). 

Ammonium urate. 

Ammonio-magnesium phosphate. 

Tricalcium phosphate. 

Calcium carbonate. 
In pathologic conditions still other unorganized substances may be 
observed, viz, cystin, xanthin, hippuric acid, indigo, urorubin, bili- 
rubin, haBmatoidin, magnesium phosphate, calcium sulphate, choles- 
terin, leucin, tyrosin, fats, soaps of magnesium, and calcium, etc. Of 
these, cystin, xanthin, hippuric acid, tyrosin, calcium sulphate, bili- 
rubin, hrematoidin, magnesium phosphate, leucin, and the soaps of 
magnesium and calcium occur principally in acid urines, while indigo, 
urorubin, and cholesterin are only usually found in alkaline speci- 
mens. Before considering these various possible constituents in de- 
tail a few Avords regarding sediments in general and the method 
to be followed in their microscopic examination may not be out of 
place. 



462 THE URINE. 

An idea of the nature of a deposit may often be formed by simple 
inspection, especially if the reaction of the urine is known. 

A crystalline sediment, presenting a brick-red color and appearing 
to the naked eye like cayenne pepper, is usually referable to uric 
acid. On the other hand, a deep red, amorphous deposit occurring 
in an acid urine will consist essentially of urates, the color in this 
case, as in the former, being due to uroerythrin. Further proof is 
hardly required. Should any doubt be felt, however, it will only be 
necessary to heat the urine, when the deposit will be seen to dissolve. 
A white, floceulent sediment in an alkaline urine is usually referable 
to a mixture of phosphates, carbonates, and alkaline urates, and will 
dissolve without difficulty upon the addition of acetic acid, while it 
remains unaffected by heat. 

A sediment, consisting of pus, and occurring in alkaline urines is 
frequently mistaken for a phosphatic deposit by the beginner. Aside 
from a microscopic examination this question may be settled by the 
addition of a small piece of caustic soda, and stirring, when in the 
presence of pus the liquid becomes mucilaginous and ropy. If much 
pus is present, a tough, jelly-like mass will be formed, which escapes 
from the vessel en masse, when the urine is poured out. Such a 
sediment, moreover, does not disappear upon the addition of an acid, 
and is rendered still more dense upon the application of heat. 

Blood, when present beyond traces, may also be recognized. 

Reliance should, however, not be placed upon the macroscopic 
appearance of a sediment to the exclusion of a careful microscopic 
examination, as those constituents, particularly the morphologic 
elements of a sediment, which are of more especial importance, can 
only be demonstrated in this manner. As a general rule, moreover, 
it may be said that the unorganized elements of a deposit are usually 
of little clinical interest. 

Students are frequently in the habit of diagnosing an excessive, 
normal, or subnormal elimination of one or another urinary con- 
stituent from the result of a microscopic examination. This is 
unwarrantable, and it should always be remembered that no con- 
clusions whatsoever can be drawn in this manner as to the amount 
actually eliminated, for nothing would be more erroneous, for ex- 
ample, than to infer an excessive excretion, not to speak of an 
excessive production, of uric acid or oxalic acid from the fact that 
crystals of these substances are seen in large numbers under the 
microscope. Again and again are cases observed in which an exces- 
sive elimination of uric acid, oxalic acid, or phosphates is diagnosed 
by mere inspection, and in which a careful chemical analysis shows 
not only no increase, but even a diminution of the normal quantity. 

A urine which is turbid when passed may be examined micro- 
scopically at once. As a rule, however, it is necessary to wait until 



MICROSCOPIC EXAMINATION OF THE URINE. 463 

a sediment has formed. The advice is usually given to allow the 
specimen to settle in a conical glass, to decant off the supernatant 
fluid as soon as a sufficient deposit has been obtained, and to 
examine a drop of the latter upon a slide covered with a cover- 
glass. This recommendation is a good one, and is usually followed. 
Not infrequently, however, it is necessary to wait for twenty-four 
hours or even longer, until a sufficient deposit has formed ; but even 
when the urine is kept covered it will frequently be found that am- 
moniacal fermentation has taken place, rendering the microscopic 
examination decidedly unsatisfactory. The urine should hence be 
kept in a clean and well-stoppered bottle until the desired deposit 
has formed. A small amount of chloroform is added, if neces- 
sary, and will preserve the specimen almost indefinitely. A few 
drops of the sediment are then removed by means of a clean pipette, 
carried down to the sediment with the distal end tightly closed with 
the finger, care being taken not to allow the urine to rush into the 
tube by suddenly releasing the pressure, but withdrawing only a 
small amount, just sufficient for an examination. This is then spread 
over a clean slide that has been moistened upon its surface by the 
breath, when the specimen may be examined at once. Covering the 
specimen ivith a slip is not only unnecessary, but even undesirable. 
A low power of the microscope should always be employed, and the 
high power only used to study details of structure. 

Of late years the centrifugal machine has been applied to urinary 
examinations, and whenever it is desired to obtain a deposit at once, 
or whenever a deposit separates out so slowly as to endanger the in- 
tegrity of the urine, an apparatus of this kind will be found very 
convenient. 

Non-organized Sediments. 

Sediments Occurring in Acid Urines. — Uric Acid. — The form 
which uric-acid crystals may present in a deposit varies greatly, the 
most common being the so-called whetstone-form shown in Fig. 
90. The crystals may occur singly or arranged in groups. Acci- 
dental impurities, such as threads or hairs, are at times covered with 
such crystals, forming long cylinders. When presenting this form 
their presence can generally not be determined macroscopieally. 
Very frequently uric acid crystallizes in the form of large rosettes 
composed of tube-shaped or long-pointed crystals, presenting a deep- 
red color, referable to uroerythrin, when they are often visible to 
the naked eye, and form the well-known briek-dust sediment at the 
bottom of the vessel. While it is generally stated that uric-acid 
crystals may always be recognized by their color, varying from a 
light yellow to a dark brown, this is not always the case, and 1 
have often observed uric acid in sediments in which the crystals, 
which in such cases formed small rhombic plates with rounded edges. 



464 THE URINE. 

occurring singly or several joined together, were absolutely devoid of 
coloring-matter, so far as a microscopic examination went (Fig. 101). 
Uric-acid " dumb-bells " are also at times observed, and may be 
mistaken for calcium oxalate. Hexagonal plates of uric acid have 
been similarly confounded with cystin. 

Fig. 101. 




Colorless crystals of uric acid. 

A uric-acid sediment is observed in cases in which an increased 
excretion of uric acid occurs, but it should be remembered that, as 
a rule, it is not permissible to infer an increased prod uction or elim- 
ination from the presence of an abundant deposit of this substance 
alone. Brick-dust sediments are frequently observed during cold 
weather ; but it would be erroneous to infer an increased elimination 
from such an occurrence, as the phenomenon is usually explained 
by the fact that uric acid is far less soluble in cold than in warm 
water. During the summer months, for the same reason, a deposit 
of uric acid is less frequently observed, although an increased amount 
may nevertheless be present, being held in solution owing to the 
higher temperature. The more concentrated the urine and the 
more uric acid it contains, the more readily will such a deposit occur. 
Whenever more water is eliminated through other channels than is 
consumed, or at least absorbed from the intestinal mucosa, such de- 
posits will occur, and are hence noted after profuse perspiration, fol- 
lowing severe muscular exercise, in acute rheumatism with copious 
diaphoresis, in acute gastritis and enteritis, profuse diarrhoea, during 
the crisis of pneumonia, particularly if accompanied by much sweat- 
ing, etc. In all these conditions, however, an increased elimination 
of uric acid does not necessarily take place, the all-important factors 
being the reaction of the urine, its degree of concentration, and the 
surrounding temperature. On the other hand, uric-acid sediments are 
frequently observed in cases in which uric acid is actually eliminated 
in increased amounts. From what has been said, however, it is clear 



MICROSCOPIC EXAMINATION OF THE URINE. 405 

that the occurrence of such deposits is usually not of much diag- 
nostic interest. 

Should formed concretions of uric acid — i. e., uric-acid gravel — be 
found in the urine, a direct indication is afforded to diminish the 
acidity of the urine and to increase the amount of water, so as to 
guard against the formation of a renal or vesical calculus. 

Chemically the nature of a uric-acid sediment may be recognized by 
the fact that the crystals dissolve upon the addition of sodium hy- 
drate, and reappear again in the rhombic form upon acidifying 
with hydrochloric acid. When heated with dilute nitric acid the 
beautiful red color of ammonium purpurate is obtained upon the 
subsequent addition of ammonia (murexid test), as described else- 
where (see p. 352). 

Amorphous Urates. — Sodium and potassium urate frequently, and 
especially in fevers, form sediments of such density that upon micro- 
scopic examination it is almost impossible to discern anything but in- 
numerable amorphous granules scattered over the entire microscopic 
field in a most irregular manner, and obscuring all other elements that 
may be present at the same time. Cells or casts that might possibly 
be discovered will frequently be seen to be studded with these 
granules. In such cases it is best to heat the urine to a tempera- 
ture of 50° C, and to filter it as rapidly as possible while still hot, 
the contents of the filter being subsequently used for microscopic 
purposes. 

Urate sediments are always colored, the tint varying from a dirty 
brown to a bright brick-red, owing to the presence of uroerythrin. 
Difficulties can hence never arise in determining the nature of the 
sediment, as a colored deposit appearing in an acid urine, which dis- 
solves upon the application of heat, cannot be due to anything but 
urates. If a drop of the sediment, moreover, is treated upon a slide 
with a drop of hydrochloric acid, some characteristic whetstone-crys- 
tals of uric acid will be seen to separate out, while the greater por- 
tion appears in the form of rhombic platelets. 

Calcium Oxalate. — This substance generally appears in urinary 
sediments in the form of small, colorless, highly refractive octahedra 
(Fig. 102), which vary greatly in size; some appear as mere specks 
even under a comparatively high magnifying power, while others 
may attain the dimensions of a large leucocyte. Frequently one 
axis is longer than the other. From the fact that their diagonal 
planes are very highly refractive, apparently dividing the superficial 
plane into four triangles, they have been compared to envelopes, and 
it is this envelope-form of the crystals which is especially character- 
istic. In the same specimen of urine so-called dumb-bell forms may 
be seen, which appear to be made up of two bundles of needle-like 
crystals united in the form of the figure 8. The latter, according to 
30 



466 THE URINE. 

Beale, originate in the uriniferous tubules, and are frequently found 
adherent to or imbedded in tube-casts. Other forms may also be 
found, and are shown in the accompanying figure. 

While the envelope crystals are highly characteristic and can 
hardly be mistaken for any other substance, the student may at times 
confound them with crystals of ammonio-magnesium phosphate. 
This error may be avoided, if it is remembered that the calcium oxa- 
late crystals are never so large as those of the magnesium salt, and 
that the latter dissolve upon the addition of acetic acid, in which 
calcium oxalate is insoluble. The distinction from uric acid, if we 
are dealing with the dumb-bell form, cannot always be made by 

Fig. 102. 




Less common forms of oxalate of lime crystals. (Finlayson. ) 

mere inspection. A drop of caustic soda should be added, which 
will dissolve the crystals if these are uric acid, while calcium oxalate 
remains unchanged. 

It has been pointed out that under strictly normal conditions a 
few isolated crystals of calcium oxalate may be found in the primi- 
tive nubecula, so that their presence in urinary sediments cannot be 
regarded as pathologic. After the ingestion of certain vegetables and 
fruits, notably rhubarb, garlic, asparagus, oranges, or following the 
continued administration of sodium bicarbonate or the salts of vege- 
table acids, calcium oxalate crystals may be observed in large num- 
bers ; so also in certain diseases, such as diabetes mellitus, catarrhal 
jaundice, phthisis, emphysema, etc. 

As in the case of uric acid, no inference can be drawn from a 
microscopic examination of the sediment as to the quantity actually 
eliminated. The frequent occurrence of abundant sediments of this 
substance may, however, generally be regarded as abnormal, pro- 
viding that such an occurrence cannot be explained by the nature of 
the diet. It is very suggestive to note the frequency with which 
such sediments are observed in certain cases of neurasthenia, associ- 
ated with a mild degree of albuminuria, as also in various digestive 



MICROSCOPIC EXAMINATION OF THE URINE. 



467 



neuroses. Finally, as in the case of uric acid, the possibility of the 
formation of renal calculi should be borne in mind, whenever abund- 
ant sediments of calcium oxalate are encountered upon frequent ex- 
amination. 

Fig. 103. 




Various forms of triple phosphates. 



(FlNLAYSON. ) 



Ammonio-magnesium phosphate, usually spoken of as triple phos- 
phate, crystallizes in large prismatic crystals of the rhombic system, 
and is most abundantly observed in alkaline urines, but is also quite 
frequently seen in feebly acid specimens. Of the various forms 
which may occur that resembling the lid of a German coffin is the 
most characteristic (Fig. 103). The size which these crystals at 
times attain is quite considerable ; very small specimens, however, 

Fig. 104. 




Crystalline phosphates. (FlNLAYSON.) 



also occur which could possibly bo mistaken for oxalate of calcium, 
but from these they arc readily distinguished by the ease with which 
they dissolve in acetic acid, as has already been pointed out. 

Here as elsewhere it should be remembered that no conclusions as 



468 THE URINE. 

to the amount actually eliminated can be drawn from a microscopic 
examination, and the diagnosis " Phosphaturia " should only be 
based upon the results of a quantitative analysis. 

Monocalcium phosphate crystals are rarely seen, and only in speci- 
mens presenting a highly acid reaction, when uric-acid crystals are 
also frequently observed in large numbers. I have only seen a few 
cases of this kind, occurring in patients the subjects of functional 
albuminuria. The urine was highly acid, in one case of a sp. gr. of 
1.036, and on standing deposited a sediment which consisted largely 
of monocalcium phosphate crystals (Fig. 105), with a considerable 
number of uric-acid crystals, from which they are readily distin- 
guished by the absence of pigment and their solubility in acetic acid. 

Neutral Calcium Phosphate. — These crystals may be found 
in alkaline, neutral, and feebly acid urines. They are at times of 
large size, but more commonly acicular, occurring either singly or 

Fig. 105. 




Monocalcium phosphate crystals. 

united together in a star-like manner (Fig. 104). They are color- 
less, readily soluble in acetic acid, and insoluble in warm water, so 
that they can be easily distinguished from uric acid. 

Basic Magnesium Phosphate crystals occurring in the form of 
large, highly refractive plates (Fig. 106), are at times seen in alka- 
line, neutral, or faintly acid and highly concentrated urines. They 
are readily recognized by treating a drop of the sediment upon the 
slide with a drop of ammonium carbonate solution (1 : 4), when the 
crystals become opaque and their edges assume an eroded aspect. In 
acetic acid they dissolve with ease and may then be reprecipitated by 
means of sodium carbonate. 

Hippuric-acid crystals have been observed, although rarely, in 
urinary sediments, in acute febrile diseases, diabetes, and chorea, 
Avhile their occurrence, following the ingestion of large amounts of 
prunes, mulberries, blueberries, or the administration of benzoic acid 
and salicylic acid is more common. 



MICROSCOPIC EXAMINATION OF THE URINE. 



469 



Hippuric acid occurs in the form of fine needles or rhombic prisms 
and columns, the ends of which terminate in two or four planes, at 
times resembling the crystals of ammonio-magnesium phosphate and 
of uric acid. From the former they may be readily distinguished by 



Fig. 106. 




Basic phosphate of magnesia crystals, (v. Jaksch.) 

their insolubility in hydrochloric acid, and from the latter by the 
fact that they do not give the murexid reaction, when treated with 
nitric acid and ammonia (see p. 352). In the case of urines rich in 
hippuric acid, in which this does not appear in the sediment, it is 
well to add a small amount of hydrochloric acid, when the crystals 
will gradually separate out. As yet their presence does not appear 
to possess any clinical significance. 

Calcium sulphate in the form of long, colorless needles or 
elongated prismatic tablets (Fig. 107), has been observed in urinary 
sediments in only two cases. In both cases the urine, especially on 
standing, deposited a milky-looking sediment, the reaction being 
strongly acid. It may be recognized by its insolubility in acids and 
ammonia. 

Fig. 107. 




Calcium sulphate crystals, (v. JAKSCH.) 



Cystin is rarely seen in urinary sediments. It occurs in the 
form of colorless, hexagonal platelets, which arc quite character- 
istic (Fig. 108). The crystals are soluble in ammonia and hydro- 
chloric acid and insoluble in acetic acid, water, alcohol, and ether. 



470 



THE URINE. 



They can thus be readily distinguished from certain forms of uric 
acid, with which they might possibly be confounded at first sight. 
When heated upon platinum foil they burn with a bluish-green flame 
without melting. Cystin-coutaining urines may be of normal appear- 
ance, but they often present a curious greenish-yellow color. Their 
reaction is mostly neutral or alkaline. Upon standing, exposed to the 
air, a marked odor of sulphuretted hydrogen develops, owing to the 
decomposition of the cystin. When treated with acetic acid a white 
crystalline sediment separates on standing, which is soluble in am- 
monia and consists of the characteristic hexagonal platelets of cys- 
tin. At times urines are met with in which a distinct odor of sul- 
phuretted hydrogen is noticeable, although crystals of cystin are not 
seen in the sediment. In these cases a careful examination should 

Fig. 108. 




Crystals of cystin spontaneously voided with urine. (Roberts.) 



be made, and it will be found that not infrequently such urine 
contain cystin in solution. It may then be demonstrated by 
strongly acidifying the urine with acetic acid, or by exposing it to 
ammoniacal decomposition. In either case cystin crystals will sep- 
arate out on standing. It should be remembered, however, that not 
all urines in which sulphuretted hydrogen is formed, contain cystin 
(see Hydrothionuria). 

The amount of cystin wdiich may be found in urinary sediments 
is variable. Sometimes a few centigrammes only are obtained while 
at others from 0.5 to 1.0 gramme may be recovered. As is the case 
with the other non-organized constituents of sediments, however, the 
amount deposited does not necessarily indicate the total amount 
present. Where a quantitative estimation of cystin is to be made, 



MICROSCOPIC EXAMINATION OF THE URINE. 471 

it is best to filter off that which is deposited and to estimate the 
amount of neutral sulphur in the filtered urine. An increase be- 
yond the normal may be referred to the cystin, remaining in solu- 
tion (see Neutral Sulphur). 

Clinical interest in connection with cystinuria centres in the fre- 
quent association of cystin sediments with cystin gravel or calculi, 
but it is curious to note that the cystinuria, notwithstanding the re- 
moval of the calculus, may persist for years without giving rise to 
symptoms denoting the existence of a pathologic process. Very re- 
markable also is the not uncommon occurrence of cystinuria in 
families. 

Of the origin of the condition very little is known. It has been 
supposed that the appearance of cystin in the urine is in some 
manner connected with the formation of certain diamins in the in- 
testinal canal. I have pointed out, however, that in all probability 
the formation of cystin and diamins occurs in the tissues of the 
body, and that the appearance of both is the expression of a definite 
metabolic anomaly, rather than of a specific infection (see p. 320). 

Leucin and Tykosin, which belong to the group of amido-acids, 
being represented by the formulae C r H 13 N0 2 and C 9 H n N0 3 , respec- 
tively, are never found in urinary sediments under normal conditions, 
while traces of both substances may be present in solution. Larger 
amounts are notably found in acute yellow atrophy, of which disease 
their presence, in sediments, was formerly regarded as pathognomonic. 
In acute phosphorus-poisoning, on the other hand, leucin and tyrosin 
are not found as a rule, so that in the differential diagnosis between 
the two conditions, the presence of these bodies may be regarded as 
indicating the existence of acute yellow atrophy. The fact that urea 
may be altogether absent from the urine in such cases, or present in 
greatly diminished amount, has already been referred to (see Urea, 
p. 324), and the elimination of leucin and tyrosin, in its stead, as it 
were, has been regarded not only as indicating the probable origin 
of urea from amido-acids, but also the formation of urea, to a large 
extent, at least, in the liver. The albuminous origin of these sub- 
stances has also been noted (see Urea). 

Smaller amounts of leucin and tyrosin are said to be constantly 
present in cases of cirrhosis of the liver, carcinoma of the liver, chole- 
lithiasis, catarrhal jaundice, Weils' disease, nephritis, cystitis, gout, 
bronchitis, tuberculosis, typhoid fever, hysteria, erysipelas, glycosuria. 
etc. In diabetic urines, on the other hand, it is supposedly absent. 
In connection with cystinuria the elimination of tyrosin has also 
been observed, but in two eases, which I examined in this direction, 
I arrived at negative results. 

As leucin is hardly ever found in the sediment, and tvrosin only 
when present in large quantities, the urine in every ease should tirst 



472 



THE URINE. 



be concentrated upon the water-bath, and examined on cooling. At 
times, however, when these substances are present in only very small 
quantities, this procedure may not lead to the desired end, and in 
doubtful cases the following method should be employed : 

The total amount of urine, voided in twenty-four hours, is precipi- 
tated with basic acetate of lead and filtered, when the filtrate, from 
which the excess of lead has been removed by means of sulphuretted 
hydrogen, is evaporated to as small a volume as possible, and set 
aside for crystallization. The residue thus obtained is then examined 
with the microscope ; if crystals are detected, which answer the 
description of tyrosin and leucin, they should be subjected to further 
chemical tests. 

Fig. 109. 




Tyrosin crystals. (Charles.) 



Ulrich advises to evaporate the urine to dryness and then to heat 
it gently, while the vessel is covered with a plate of glass or a fun- 
nel. The tyrosin is then said to sublime and is deposited on the 
cool glass in crystalline form, the crystals showing the characteristic 
reactions. 

Tyrosin crystallizes in the form of very fine needles (Fig. 109), 
which are usually grouped together in sheaves or bundles, crossing 
each other at various angles. They are insoluble in acetic acid, but 
soluble in ammonia and hydrochloric acid. 

Leucin (Fig. 110) occurs in the form of spherules of variable size, 
which closely resemble globules of fat, but may be distinguished from 
these by their insolubility in ether. In the urine they present a 
more or less pronounced brownish color, and upon close examina- 
tion concentric striations as well as very fine radiating lines can at 
times be made out, which are especially characteristic. 

If crystals resembling tyrosin and leucin are found, the following 
tests should be made : 

In order to separate the leucin from the tyrosin, the residue is 
treated with a small amount of alcohol, in which leucin is more 
readily soluble than tyrosin. 



MICROSCOPIC EXAMINATION OF THE URINE. 



473 



Tests for Tyrosin. — The sediment is filtered off, washed with water 
and dissolved in ammonia, to which a little ammonium carbonate has 
been added. This solution is allowed to evaporate, and leaves the 
tyrosin behind. 

Pirla/s Test. — A bit of the tyrosin is moistened on a watch 
crystal with a few drops of concentrated sulphuric acid, covered, 
and set aside for half an hour. It is then diluted with water, heated, 
and while hot saturated with calcium carbonate and filtered. The 
filtrate is colorless, but when heated with a few drops of a very dilute 
solution of perchloride of iron, which must be free from hydrochloric 
acid, it assumes a violet tint (v. Jaksch). 

Fig. 110. 




Crystals of leucin (different forms). (Crystals of kreatinin chloride of zinc resemble the leucin 
crystals depicted at a.) The crystals figured toward the right consist of comparatively impure 
leuciu. (Charles.) 

Hoffmann's Test. — A small amount of tyrosin, when dissolved 
in hot water and treated, while hot, with mercuric nitrate and potas- 
sium nitrite, imparts to the solution a beautiful dark-red color, and 
yields a voluminous red precipitate. 

Tests for Leucin. — Scherer's Test. — To test for leucin, this is 
separated from tyrosin, as described, by the addition of a little alco- 
hol. The alcohol is allowed to evaporate, and a portion of the resi- 
due treated upon platinum-foil with nitric acid, when a colorless 
residue is obtained, which, upon the application of heat and a few 
drops of a solution of sodium hydrate, forms a droplet of an oily 
fluid which does not adhere to the platinum. 

Hofmeister's Test. — A small amount of leucin dissolved in 
water causes a deposit of metallic mercury when heated with mer- 
curous nitrate. 

XANTHIN crystals (Fig. Ill) arc very rarely observed in urinary 
sediments, and, so far as I have been able to ascertain, the case ob- 
served by Bence Jones is the only one cm record, ("arc should be 
had not to confound certain forms of uric acid with xanthin, and 1 
well remember an instance in which crystals were observed, identical 
in appearance with those here pictured, but which upon chemical 



474 



THE URINE. 



examination proved to be uric acid. The necessity of disregarding 
the statement generally made that uric-acid crystals found in urinary 
sediments are invariably colored cannot be insisted upon too strongly. 
It has been stated elsewhere that colorless uric-acid crystals may be 
encountered, and in the case just cited this was observed. 



Fig. 111. 



<^ 



0^7 



^www^ 



u? 



J- 



^ 



O 



a, Crystals of xanthin (Salkowski); b, Crystals of cystin (Robin). 

Clinically, xanthin sediments are of interest only in so far as this 
substance may give rise to the formation of calculi ; in the case 
observed by Bence Jones attacks of renal colic had occurred several 
years previously. 

Soaps of Lime and Magnesia. — v. Jaksch has pointed out that 

Fig. 112. 




Lime and magnesium soaps, (v. Jaksch. ) 



in various diseases crystals may be found which " closely " resemble 
tyrosin in appearance, and pictures such crystals (Fig. 112), which 
from their behavior toward reagents he is inclined to regard as cal- 
cium and magnesium salts of certain higher fatty acids. 



MICROSCOPIC EXAMINATION OF THE URINE. 475 

Should any doubt arise, the question may be readily decided by a 
chemical examination (see tests for tyrosin and fatty acids). 

Bilirubin crystals in the form of yellow or ruby-red rhombic 
plates or needles, as well as amorphous granules, have been seen in 
the urine in rare cases, but are of no special interest. They are 
easily soluble in alkalies and chloroform, but not in ether. When 
treated upon a slide with a drop of nitric acid, a green ring will be 
seen to form around them (Gmelin's reaction). 

H^ematoidin crystals are likewise only rarely seen. They 
cannot be distinguished from bilirubin by the microscope, and also 
resemble the latter chemically to such a degree that Hoppe-Seyler 
regarded the two as practically identical. They may be found either 
free or imbedded within cells or tube-casts, in cases of scarlatinal 
nephritis, the nephritis of pregnancy, in granular atrophy, amyloid 
degeneration of the kidneys, and in carcinoma of the bladder, of which 
latter condition they have been regarded by some as pathognomonic. 

It has been stated that hsematoidin crystals may be distinguished 
from bilirubin crystals by the appearance of a transient blue color, 
when treated with nitric acid, but v. Jaksch rightly regards this re- 
action as of doubtful value, as a blue color is similarly obtained when 
bile-stained elements of a urinary sediment are treated in this manner. 

Fat.— When small, strongly refractive globules of fat, which 
may be readily recognized by their solubility in ether, are observed 
either floating on top of the urine or held in suspension, it is neces- 
sary to ascertain first of all whether such fat may not have been in- 
troduced into the urine accidentally, owing to the use of a bottle or 
vessel not absolutely clean, previous catheterization, etc. The di- 
agnosis Lipuria should only be made when all possible precautions 
have been taken to insure against the accidental presence of this sub- 
stance. Every physician who has frequent occasion to examine urines 
has undoubtedly met with instances in which fat-globules were found, 
and in which a careful inquiry showed that these were only acci- 
dentally present. True lipuria, i. <?., an elimination of fat, usually 
in the form of minute droplets floating in the urine, has been noted 
in various cachectic conditions, in cases of heart-disease, affections of 
the pancreas and liver, in gangrene, and pyaemia, in diseases of the 
bones, especially following fractures, in diseases of the joints, etc. 
Fat has also been observed in the urine following the ingestion of 
large amounts of cod-liver oil and inunctions with fats and oils. 

In fatty degeneration of the kidneys, in Bright's disease, phosphorus- 
poisoning, etc., minute droplets of fat may be seen in the epithelial 
cells and tube-casts. The true nature of these may be recognized by 
their solubility in ether, benzol, chloroform, carbon bisulphide, xylol, 
etc., and the fact that they are colored black when treated with a 
0.5- to l.O-per-cent. solution of osmic acid, and red when a drop of 



476 THE URINE. 

tincture of alcanna is added to the specimen. A very convenient 
method of demonstrating the presence of fat is also the following : 
A few cubic centimetres of the urine are mixed with an equal volume 
of 96-per-cent. alcohol, and a concentrated solution of Sudan III, 
in 96-per-cent. alcohol. The sediment, which soon collects, is then 
examined under the microscope ; the excess of stain is removed 
by allowing a few drops of 60- or 70-per-cent. alcohol to run under 
the coverslip and removing it with filter paper, placed at the edge 
of the preparation. The fat droplets are thus colored an intense 
scarlet red, while granules of albuminous origin are unstained. Free 
fat can of course be demonstrated in the same manner. 

The occurrence of fat-droplets in the morphologic elements of a 
urinary sediment should not be regarded as a form of lipuria. 

The largest amounts of fat are observed in chyluria, a condition 
which is usually due to the presence of a distinct parasite in the 
blood, the filaria sanguinis hominis, or more rarely the distoma 
haematobium, which has been referred to in the chapter on Blood 
(see Chyluria). 

Sediments Occurring in Alkaline Urines. 

Basic Phosphates of Calcium and Magnesium. — The most common 
sediments observed in alkaline urines consist of amorphous phos- 
phates of calcium and magnesium. They are usually as abundant 
as the urate sediments, which have already been described, but may 
be readily distinguished from these by the fact that they do not dis- 
solve upon the application of heat, but readily disappear upon the 
addition of acetic acid, and are never colored. In this manner it is 
also easy to distinguish such a sediment from one due to pus, with 
which it might possibly be confounded at first sight. Upon micro- 
scopic examination a drop of the sediment will be seen to contain 
innumerable transparent granules, scattered over the entire field, 
and closely resembling those of urate of sodium and potassium. 

Phosphatic sediments are observed, as mentioned elsewhere, when- 
ever the reaction of the urine is alkaline, whether this is owing to 
the presence of fixed alkalies or to ammoniacal fermentation. 

Ammonium urate is only observed in urines which are undergoing 
ammoniacal fermentation. Its presence should always call for a 
careful investigation in order to ascertain whether this has taken 
place after the urine has been voided or before (see Reaction). 

The salt occurs in the form of colored spherical bodies of variable 
size, which are frequently beset with prismatic spicules, and are not 
easily mistaken for any other substance which may be present in 
urinary sediments (Fig. 113). It is characterized, moreover, by its 
solubility in acetic and hydrochloric acids, and the subsequent sepa- 
ration of rhombic crystals of uric acid. 



PLATE XVII 



WjbV'-jFlK 




Indigo Crystals from a Urine Rich in Indiean, after standing for Eight Days 
at Ordinary Temperature. (V. Jakseh.) 



MICROSCOPIC EXAMINATION OF THE URINE. 



477 



Magnesium phosphate has been described above (see p. 468). 

Ammonio-magnesium phosphate. — While the well-known coffin-lid 
crystals are commonly seen in feebly acid urines, as pointed out, am- 
monio-magnesium phosphate presents a great variety of forms in al- 
kaline urines, and especially in specimens undergoing ammoniacal 
fermentation (see Fig. 103). 

Fig. 113. 




Ammonium urate crystals. 



Calcium Carbonate frequently occurs in alkaline urines, and 
appears under the microscope in the form of minute granules, occur- 
ring singly or arranged in masses ; dumb-bell forms are also seen 
(Fig. 114). They may be recognized by the fact that they readily 
dissolve in acetic acid with the evolution of <ras. 



Fig. 114. 







Calcium carbonate crystals. 

Indigo in the form of delicate blue ueedles ( Plate XVIL), arranged 
in a stellate manner or in plates, visible only with the microscope, is 
rarely seen, and a specimen, such as the one which v. Jaksch pic- 
tures, can only be regarded as a medical curiosity. In an amor- 
phous condition, however, indigo may be met with in almost every 
decomposed urine, occurring in the form of small granules, and fre- 
quently staining the morphologic elements that may be present a 



4' 



THE URINE. 



distinct blue. Sediments which present a bluish-black color were 
already noted at the time of Hippocrates, and have since been de- 
scribed by numerous observers, although the true nature of the col- 
oring-matter has only been determined within the last fifty years. 
Clinically the occurrence of indigo in the urine is of interest only 
in so far as renal calculi have been observed which consisted almost 
entirely of this substance. But little is known of the causes which 
a:ive rise to its appearance in the urine, but there can be no doubt 
that its occurrence is referable to the action of certain micro-organ- 
isms upon urinary indican (see p. 456). 

Organized Constituents of Urinary Sediments. 

Epithelial Cells. — (Fig. 115.) Bearing in mind the fact that 
desquamative processes are constantly going on in the epithelial 



Fig. 115. 




Epithelium from the urinary passages. 
a, Round cells ; b, conical and caudate cells ; c, fiat cells. 

lining of the various cavities and channels of the body, one should 
expect to find in every urine representatives of the different forms 
of epithelium occurring in the urinary organs, from the Malpighian 
tufts down to the meatus ur inarms. To a certain extent this actu- 



MICROSCOPIC EXAMINATION OF THE URINE. 479 

ally happens, and cells apparently derived from the meatus, the 
urethra, bladder, ureters, and pelvis of the kidneys may be met with 
in almost every specimen, although it may at times be difficult to 
refer the individual cells observed to their proper origin. Bizzozero 
even claims that it is impossible to distinguish between the cells of 
the bladder and those of the meatus and renal pelvis, while, as a 
class, they may be readily differentiated in most cases from the cells 
of the urethra, the ureters, the prepuce of the male and the vulva 
and vagina of the female. Cells from the uriniferous tubules of the 
kidneys, on the other hand, are seldom seen in normal urines, and 
when they do occur it is impossible to determine their exact origin ; 
i. e., the particular portion of the tubule from which they have been 
detached. Cells presenting the characteristic striated appearance 
seen in the irregular, and to a less evident degree in the convoluted 
portions of the uriniferous tubules, are never observed in the urine. 
This fact, as well as the usual absence of true glandular cells, re- 
mains as yet to be explained. It does not appear improbable that 
the absence of these cells may be referable to a less marked degree 
of desquamation going on in those parts, in which the mechanical 
injury to which the epithelium is subject must of necessity be far 
less severe, than in the remaining portions of the urinary tract, and 
particularly in the bladder and urethra. 

As has been stated elsewhere, the number of epithelial cells occur- 
ring in urinary sediments under physiologic conditions is small, and 
the presence of large numbers may hence always be regarded as 
abnormal, and indicating the existence of a circulatory or inflamma- 
tory disturbance affecting some portion of the urinary tract. 

Were it possible in every case to determine the exact origin of the 
cells, it is evident that information of great value could thus be 
obtained, and that it would be a comparatively simple matter to 
localize the lesion. Unfortunately this is not always possible, as the 
form of the cells is dependent to a certain extent upon the reaction 
of the urine, an alkaline or neutral reaction causing the cells 
to swell and to appear larger and rounder than is the case in 
acid urines. As has been mentioned, the cellular type i- prac- 
tically the same, moreover, in the bladder, ureters, and pelvis of the 
kidneys. 

Definite conclusions should hence bo drawn only exceptionally 
from a microscopic examination alone, but there can be no doubt 
that in conjunction with other factors and the clinical history the 
demonstration of a normal or increased number of epithelial cells 
may frequently be of decided value in a differential diagnosis, ami 
taking these factors into consideration it may even be possible to 
localize the seat of the lesion. If attention is directed to the struc- 
ture of tlu 1 individual cell, and this holds o^ood move especially tor 



480 THE URINE. 

the cells derived from the uriniferous tubules, an idea may at times 
even be formed of the character of the lesion (see below). 

Ultzmann recognizes three forms of epithelial cells which may be 
found in urinary sediments, viz : 

1. Round cells. 

2. Conical and caudate cells. 

3. Flat cells. 

Round cells are usually derived from the uriniferous tubules and 
the deeper layers of the mucous membrane of the pelvis of the kid- 
neys. In the urine they present a more or less rounded form and 
are provided with a distinct nucleus ; they are not much larger than 
pus-corpuscles. From the latter they are distinguished by the pres- 
ence of a well-defined nucleus, which in pus-cells becomes distinct 
only upon the addition of acetic acid, and is moreover, polymorphous. 
Whenever such cells are found adhering to urinary casts, which may 
at times consist entirely of these structures, it is clear that they repre- 
sent the glandular elements proper of the kidneys. As similar cells 
are found in the male urethra, some confusion may possibly arise. 
Should albumin, however, be present, the probabilities are that the 
cells are of renal origin. The presence of such cells in large num- 
bers together with pus, in the absence of tube-casts and albumin, 
beyond traces, will usually indicate the existence of a simple pyelitis, 
particularly if round cells are found joined together in a shingle-like 
manner. Should the pyelitis be associated with a nephritis, tube- 
casts and albumin in larger amounts will at the same time be present. 
In such cases it may be impossible to determine the origin of the 
cells, excepting of such that may adhere to casts. In simple 
circulatory disturbances affecting the renal parenchyma no special 
abnormalities can be discovered in the structure of the cells, while 
in cases of fatty degeneration of the kidneys they will be seen to 
contain fatty particles in greater or less abundance, so that it may 
be possible to determine the existence of degenerative processes 
which may be of inflammatory or non-inflammatory origin. The 
same may be said to hold good, if the epithelial elements are mark- 
edly granular and occur in fragments. 

Conical and caudate cells are mostly derived from the superficial 
layers of the pelvis of the kidneys, and are hence especially seen in 
cases of pyelitis. Similar cells are also found in the neck of the 
bladder, and may usually be distinguished from those of the pelvis, 
by the greater length of their processes. 

Flat cells may come from the ureters, the bladder, the prepuce of 
the male, and the vulva and vagina of the female. These cells pre- 
sent the usual characteristics of squamous epithelium, being large, 
polygonal in form, and provided with a well-defined nucleus ; the 
extra-nuclear protoplasm is only slightly granular. Other more or 



MICROSCOPIC EXAMINATION OF THE URINE. 481 

less rounded forms are also seen which are derived from the deeper 
layers of the mucosa, but may be distinguished from the small round 
cells of the kidneys proper. Irregular or conical cells, often provided 
with one or more protoplasmic processes, likewise come from the 
lower layer of the mucosa of the bladder and ureters. 

While the cells of the bladder may thus be confounded Avith those 
of the ureters and vagina under the microscope, it is not likely that 
a vaginitis or vulvitis will be mistaken for a cystitis or a ureteritis. 
In doubtful cases specimens of urine should be procured by means 
of the catheter, care being taken to first thoroughly cleanse the vulva. 
The warped appearance so frequently seen in vaginal epithelial cells, 
and the fact that they often and indeed usually appear in masses, 
may further aid in the differential diagnosis. 

It has been pointed out by Peyer that the presence of pavement- 
epithelial cells, together with mucus and leucocytes, in the urine of 
hysterical and anaemic girls may be regarded as indicating an irrita- 
tive condition of the genitals, possibly in consequence of masturba- 
tion. Bearing in mind the moist and sensitive condition of the vulva 
of female masturbators, such a view appears plausible. 

A ureteritis, notwithstanding the fact that the ureteral cells closely 
resemble those of the bladder, may be inferred indirectly, the pres- 
ence of squamous cells in abundance pointing to a cystitis, a small 
increase in their number to ureteritis. In conclusion, it should be 
stated that the so-called mucous corpuscles present in every urine 
are nothing more than young vesical cells. 

From what has been said it is clear that, with due precautions and 
taking other factors into consideration, the discovery of epithelial 
cells in large numbers in urinary sediments may be of decided value 
in diagnosis. 

Leucocytes. — Leucocytes are only encountered in very small 
numbers in normal urines. A marked increase should, hence, always 
be regarded as indicating the existence of disease somewhere in the 
course of the urinary tract, excepting in females, where their presence 
may be owing to an admixture of leucorrhoeal discharge. In that 
case the source of the pus will generally be recognized by the simul- 
taneous occurrence of pavement-epithelial cells of the vaginal type, in 
correspondingly large numbers. In doubtful cases the urine should 
always be obtained with the catheter, care being taken to thoroughly 
cleanse the vulva before the introduction of the instrument. 

Occasionally the pus is derived from a neighboring abscess that 
has opened into the urinary passages. 

The amount of pus which may be found in urines is most variable. 
On the one hand, deposits several em. in height are not at all un- 
common, and closely resemble deposits of phosphates in appearance, 
lor which they are indeed frequently mistaken ; on the other hand, 
31 



482 ' THE URINE. 

it may only be possible to discover the presence of pus by means of 
the microscope, which should be employed in every case. 

The appearance of the pus-corpuscles likewise varies in different 
cases : In acid urines their form is usually well preserved, and in 
feebly alkaline and neutral specimens it may even be possible to 
observe amoeboid movements, when the slide is carefully warmed. 
In alkaline urines, however, they usually swell up and become 
opaque, so that it is impossible to discern their nuclei unless they 
are treated with acetic acid. At other times, and particularly when 
pus has long remained in the body, as where a neighboring abscess 
has burst into the urinary passages, it may almost be impossible to 
make out a nucleus, and in extreme instances nothing but a mass of 
granular and fatty detritus is left. 

While with a certain degree of experience it is hardly likely that 
a sediment of pus will be mistaken for anything else, such as a de- 
posit of phosphates, it should be remembered that, if pus is exposed 
to the action of ammonia, or an ammonium salt, the pus-corpuscles 
become disintegrated. In such cases, as in cystitis, in which 
ammoniacal decomposition of the urine has taken place in the bladder, 
a deposit may be obtained which macroscopically resembles mucus, 
and in which pus-corpuscles may not even be demonstrable with the 
microscope. The sediment then escapes as a gelatinous, slippery 
mass when the urine is poured from one vessel into another. Ke- 
course must then be had to certain chemical tests, as a pyuria might 
otherwise be overlooked. To this end the following procedure, sug- 
gested by Vitali, may be employed : 

The urine, after having been acidified with acetic acid, is filtered, 
and the contents of the filter treated with a few drops of tincture of 
guaiacum which has been kept from the light, when in the presence 
of pus the filter-paper is colored a deep blue. 

A solution of iodo-potassic iodide may be employed in less extreme 
instances. A drop of this solution is added to a drop of the sedi- 
ment upon a slide, when the pus-corpuscles, owing to the presence of 
glycogen, are colored a dark mahogany-brown, while epithelial cells, 
with certain forms of which they might possibly be mistaken, assume 
a light color. 

Donne^ s pus-test is based upon the fact that the transformation of 
pus into a gelatinous, mucus-like mass, observed in cases of cystitis, 
owing to the action of ammonium carbonate, may also be artificially 
produced by the addition of a small piece of caustic soda, and stir- 
ring, when in the presence of pus in small amounts the liquid be- 
comes mucilaginous and ropy, while a gelatinous mass is obtained if 
it is abundant. 

From a clinical point of view it is most important to establish the 
source of the pus in every case of pyuria. This may at times be 



MICROSCOPIC EXAMINATION OF THE URINE. 4S3 

difficult, but the following data will be found of value in a differen- 
tial diagnosis : 

1. In diseases affecting the renal parenchyma the amount of pus, 
as a rule, is small, except where a large abscess located in the kidney 
structure proper has suddenly burst into the pelvis of the kidney. 

In uncomplicated cases it is a comparatively easy matter to recog- 
nize the renal origin of the pus, as other constituents, such as renal 
epithelial cells, and especially tube-casts, are usually present at the 
same time, and, as was noted in the case of renal epithelial cells, 
leucocytes are quite frequently found adhering to the tube-casts, and 
at times apparently compose these entirely, when they are spoken of 
as pus-casts (see Casts). In nephritis, according to Bizzozero, the 
number of pus-corpuscles stands in a direct relation to the intensity 
and acute character of the morbid process, the greatest number 
being found in cases of acute nephritis, while in the chronic forms 
their number is usually insignificant. Whenever, in the course of a 
chronic nephritis, large numbers of pus-corpuscles appear, they may 
be regarded as indicating, either an acute exacerbation of the disease, 
or a complicating inflammation of some portion of the urinary tract. 
In such cases errors may be guarded against by carefully observing 
the number and character of the epithelial cells present at the same 
time, when it will often be found that what at first sight appears as 
an acute exacerbation of a chronic process, judging from the number 
of pus-corpuscles, is in reality a secondary pyelitis, ureteritis, or 
cystitis. 

In cases of simple renal hyperemia pus-corpuscles never occur in 
notable numbers. 

2. In pyelitis the amount of pus eliminated may vary consider- 
ably, and at times even perfectly normal urine may be voided. This is 
probably owing to the fact that the ureter of the affected side, if 
the disease is unilateral, becomes obstructed temporarily, when sud- 
denly large quantities may again appear. The diagnosis of pyelitis 
is often difficult, and should be based not only upon the condition of 
the urine, but upon the clinical symptoms. Very significant is the 
fact that the urine in pyelitis is usually acid, a point to be remem- 
bered in the differential diagnosis between this condition and cystitis, 
with which pyelitis is quite frequently confounded. A careful ex- 
amination of the epithelial elements may also be of value, and should 
never be neglected. Bacteria in large numbers are generally present. 

When pyelitis is associated with nephritis it may at times be 
almost impossible to determine the origin of the pus, but if the rule 
set forth above is remembered, that in chronic nephritis the number o{ 
leucocytes is always small, it is not likely that a pyelitis will be over- 
looked, particularly if the clinical symptoms are taken into consider- 
ation. 



484 THE URINE. 

Matters may become still more complicated when a cystitis is ac- 
companied by a pyelitis or a pyelonephritis. Catheterization of the 
ureters, the feasibility of which, even in the male, has been clearly 
demonstrated by the late Dr. James Brown, should then be resorted 
to, and it is highly desirable that this most valuable method of diag- 
nosis should become common property, as soon as possible. Fischl 
regards the presence of cylindrical masses composed of pus-cor- 
puscles, formed in all probability in the papillary ducts, as highly 
characteristic of pyelitis. In the examination of a number of cases 
of this kind, however, I have never been able to demonstrate their 
presence. 

3. A pyuria referable to ureteritis can hardly be diagnosed from 
the appearance of the urine, and in suspected cases catheterization of 
the ureters should be resorted to, which may possibly elicit some in- 
formation of value. 

4. In mild cases of cystitis pus may be altogether absent, while in 
the more severe forms its presence is constant. In cystitis the larg- 
est amounts, referable to disease of the urinary organs, are observed, 
and are exceeded only in those rare conditions, in which a neighbor- 
ing abscess has suddenly opened into the urinary passages. 

As the urine in cystitis is usually alkaline, and always so in the 
more severe forms, the alkalinity being due to ammoniacal fermen- 
tation, it may happen, owing to the disintegrating action of the am- 
monium carbonate upon the pus-corpuscles, that these may not even 
be demonstrable with the microscope, and that a gelatinous, mu- 
coid sediment appears instead, which escapes from the vessel en 
masse, when the urine is poured out. Vi tali's test for pus (referred 
to on p. 482) should be employed in such cases. 

5. In urethritis pus may be present in the urine in considerable 
amounts. The source of the pus is recognized by the fact that a 
drop may be manually expressed from the urethra, particularly in 
the morning upon awaking. Mucoid gonorrhoea! threads, — the 
" Tripperfaden " of the Germans, — which are largely composed of 
pus-corpuscles will almost always be detected in the urine in such 
cases (Fig. 126). In order to distinguish between a simple urethritis 
and a urethritis complicated with cystitis, the urine should be ob- 
tained in two portions and allowed to settle. In simple urethritis, 
affecting the anterior portion of the urethra, the first specimen is 
cloudy, while the second one is clear. If the urethritis, however, 
has extended to the neck of the bladder, in the absence of cystitis, 
the first portion will, of course, be cloudy, while the second may 
present a variable appearance, being clear at times and cloudy at 
others. This phenomenon is explained by the fact that a portion of 
the pus contained in the posterior portion of the urethra has found 
its way into the bladder. A cystitis may, however, be excluded by 



MICROSCOPIC EXAMINATION OF THE URINE, 485 

the acid reaction of the second specimen, and the fact that the latter 
is never so cloudy as the first. In cases of urethritis complicated 
with a purulent cystitis the second portion of the urine contains at 
least as much pus as the first, and usually more, owing to the fact 
that the pus, which is heavier than the urine, falls to the floor of the 
bladder, in which case also the last drops passed will often be found 
to be pure pus. The reaction of the urine, moreover, will then gen- 
erally be alkaline. 

6. A sudden elimination of large quantities of pus with a urine, 
which up to that time has presented a normal or nearly normal ap- 
pearance, may almost always be referred to the rupture of a neigh- 
boring abscess into the urinary passages. Exceptions to this rule 
have been noted in rare instances in which large amounts of pus 
suddenly appeared, the origin of which could not be demonstrated 
upon post-mortem investigation. Whether such a phenomenon, as 
v. Jaksch suggests, is dependent upon " unusual conditions favoring 
diapedesis ;? remains an open question. 

Enumeration of the Pus Corpuscles in the Urine. — In order to deter- 
mine the relation existing between the degree of pyuria and albumin- 
uria, as well as to watch the progress of an individual case, an enu- 
meration of the number of pus-corpuscles is at times necessary. 
To this end a specimen of the urine is thoroughly shaken and the 
number of corpuscles contained in one cubic millimetre ascertained 
with the aid of the Thoma-Zeiss blood counter. Dilution with a 
three-per-cent. solution of common salt is necessary, when a pre- 
liminary examination has shown the presence of more than 40,000 
corpuscles per cbmm. A dilution of five times is usually sufficient. 
In every case one hundred squares, at least, should be counted. 

Same of the results which have thus been obtained are extremely 
interesting. In light cases of cystitis 5,000 pus-corpuscles are 
found on an average in the cubic millimetre ; in cases of moderate 
severity from 10-20,000, while in severe cases 50,000 and even more 
may be seen. In one case of cystitis, complicating carcinoma of the 
bladder, Hottinger obtained 15*2,000 per cbmm. In the presence of 
less than 50,000 a mere trace of albumin is found, and with 80,000— 
100,000 only one pro mille is referable to this source. 

Red Blood-corpuscles. — The presence of red blood-corpuscles in 
the urine, constituting the condition usually spoken of as hoematuiHa, 
is observed only in pathologic conditions, and is, in contradistinc- 
tion to hemoglobinuria (which see), a very common occurrence. 

Urine containing blood-corpuscles in notable numbers presents a 
color which may vary from a bright red lo a dark brown, verging 
upon black. Upon standing, a sediment of a corresponding color is 
obtained in which distinct coagula of variable size arc at times seen. 

If the urine should only contain a small number of red corpus- 



486 THE URINE. 

cles, however, no deviation from its normal appearance will be 
noted, and the diagnosis of hsematuria can then only be made with 
the microscope, which should be employed in every case. The ap- 
pearance of the red corpuscles varies greatly, being influenced espe- 
cially by the length of time during which they have been exposed to 
the urine. In cases of hsematuria of urethral or vesical origin it 
will be found that they have mostly retained their normal appearance 
fairly well, or have become crenated, when they may be recognized 
without difficulty. Other corpuscles, however, will probably also be 
seen which are no longer biconcave, but which have become spher- 
ical or shrunken, and present an irregular outline. In cases, on the 
other hand, in which the corpuscles have remained in the urine for a 
longer time, as in hsematuria of renal origin, the inexperienced will 
frequently be puzzled by the presence of small bodies of the size of 
red corpuscles, or somewhat smaller, which are entirely devoid of 
coloring-matter, and merely appear as faint, transparent rings, often 
presenting a double contour, and in which no nucleus can be discov- 
ered. These formations are red blood-corpuscles from which the 
haemoglobin has been dissolved. They are usually spoken of as 
blood-shadows. Chemical tests are rarely necessary, but may be em- 
ployed, if any doubt should arise (see p. 401). 

Clinically it is, of course, all-important to determine the source of 
the blood. This may at times be accomplished without much diffi- 
culty by a urinary examination, but at other times it may almost be 
impossible, when the clinical symptoms and physical signs must be 
taken into consideration. 

1. Hematuria of urethral origin, due to urethritis, or traumatism 
incident to catheterization, for example, is a common event, and 
readily diagnosed, as in such cases blood either escapes of its own 
accord from the urethra, or may be squeezed out manually. The last 
portion of the urine voided, moreover, will always be found free 
from blood, unless the latter is referable to disease of the neck of the 
bladder, when the blood appears only toward the end of micturition, 
or at least more markedly then than in the beginning. 

2. The diagnosis of vesical hsematuria is not always easily made. 
It should be remembered, however, that the blood-corpuscles here 
present a normal appearance, as has been mentioned, unless ammo- 
niacal fermentation is occurring in the bladder, in which case blood- 
shadows are seen in large numbers. The blood, moreover, is less 
intimately mixed with the urine than in cases of renal hsematuria, 
so that the corpuscles rapidly settle after the urine has been passed. 
Blood-clots of an irregular form and considerable dimensions can 
only be of vesical origin. A careful examination for the presence 
of any other morphologic constituents which may be observed in 
urinary sediments, when considered in conjunction with the clinical 



MICROSCOPIC EXAMINATION OF THE URINE. 487 

symptoms, will usually lead to a correct diagnosis so far as the seat 
of the hemorrhage is concerned. Hematuria of vesical origin may 
be due to numerous causes, among which may be mentioned diph- 
theritic cystitis, ulcers of the bladder caused by calculi and carcinoma, 
traumatism, the presence of parasites, and, more rarely, rupture of 
varicose veins in the bladder. In determining the cause of the 
hemorrhage in a given case more reliance should be placed upon the 
clinical history than upon the urinary examination. 

3. In hematuria of ureteral origin characteristic blood-coagula, 
corresponding in diameter and form to the ureters are occasionally 
seen. Their presence, however, does not necessarily indicate that 
the blood has come from the ureters ; more frequently the hemor- 
rhage will be found to be due to disease of the pelvis of the kidney. 

4. The diagnosis of hemorrhage into the pelvis of the kidney 
must be based upon the clinical symptoms taken in conjunction with 
the results of a urinary examination. In nephrolithiasis only a small 
number of red corpuscles is usually found. 

5. Hematuria of purely renal origin is of common occurrence, and 
may be due to numerous causes. In simple hypersemic conditions of 
the organs and in acute nephritis the passage of smoky-looking urine 
containing blood-corpuscles, usually in large numbers, is thus a fairly 
constant symptom. In chronic nephritis the number of the red cor- 
puscles may be taken to indicate the intensity of the morbid process. 
Hematuria may also be due to renal abscess, nephrophthisis, renal 
carcinoma, and, in rare instances, to aneurysm and embolism of the 
renal artery, thrombosis of the renal vein, etc. In the malignant 
forms of the acute infectious diseases, such as small-pox, yellow fever, 
malaria, etc., in scurvy, haemophilia, and purpura, in leukaemia, fila- 
riasis, and distomiasis, renal hsematuria is common. It is also ob- 
served in cases of poisoning with turpentine, carbolic acid, canthar- 
ides, etc. 

6. An idiopathic form of hematuria has also been described, in 
which hemorrhage from the kidneys occurs without apparent cause. 
To this form Senator has applied the term "renal haemophilia." I 
have seen three cases of this kind in which no lesion existed which 
could be made responsible for the hemorrhage. In all three the at- 
tacks of hematuria were invariably associated with anachlorhydria, 
while normal values were found between the attacks. Two oi' the 
patients were males and undoubtedly neurasthenics. The third was 
a hysterical chlorotic female, in which hseraatemesis, pulmonary hem- 
orrhages, and mehena were 4 also at times observed. 

Hematuria of renal origin is usually recognized without much dif- 
ficulty, as in such cases tube-casts, bearing red blood-corpuscles, and 
at times apparently consisting of these altogether, as well as numbers 
of renal epithelial cells, will usually be found upon careful examina- 



488 THE URINE. 

tion. The blood, moreover, is intimately mixed with the urine, and 
the individual corpuscles have mostly lost their hsemoglobin and ap- 
pear as mere shadows. The clinical history should, of course, 
always be taken into consideration, and especially in determining the 
primary cause of the hemorrhage. 

Urine containing red blood-corpuscles is always albuminous, so 
that it may sometimes be difficult to decide in a given case whether 
the albumin found is due solely to the presence of blood, or whether 
the hematuria is complicated with an albuminuria per se. Fre- 
quently it is possible to arrive at some conclusion by comparing the 
amount of albumin with the number of the red corpuscles, the 
presence of a large amount of the former in the presence of only a 
small number of the latter indicating that the albumin is not alto- 
gether due to the blood. At other times it is impossible to gain 
information in this manner, when the only expedient left is to deter- 
mine the quantity of albumin and of iron separately, and to ascertain 
whether the amount of iron found is sufficient to combine with that 
of the albumin. As a rule, however, the presence of serum-albumin, 
aside from that contained in the blood of the urine, may be inferred 
whenever tube-casts are present, although the amount can only be 
estimated approximately in this manner. 

Tube-casts. — In various pathologic conditions, and it is claimed 
even in health, curious formations are seen in the urine, which repre- 
sent moulds of different portions of the uriniferous tubules. To these 
the term tube-casts or urinary cylinders has been applied, and it may 
be said that there is hardly a subject of greater importance in urinary 
analysis, from a clinical point of view, than that of cyhndruria ; but 
it must also be admitted that notwithstanding numerous investigations 
our knowledge of their nature and mode of formation is still defective, 
and the same may be said of their clinical significance. The term 
" tube-casts," however, is not altogether appropriate, as it is only 
applicable to one great division of such formations — i. e., to those 
consisting of a uniform, transparent, gelatinous matrix to which other 
elements, such as epithelial cells, red blood-corpuscles, leucocytes, 
and salts in a crystalline or amorphous form, may accidentally have 
become attached — the tube-casts proper. 

From these the so-called " pseudo-casts " must be sharply differ- 
entiated, a pseudo-cast being characterized essentially by the absence 
of a uniform matrix. Closely related apparently to the true casts 
are the so-called cylinclroids, i. e., band-like formations which resemble 
the former in appearance, and like these may carry various morpho- 
logic elements as well as salts. It is thus necessary to distinguish 
between true casts, pseudo-casts, and cylindroids. Of these the true 
casts are by far the most important and the most common. They 
may be divided into hyaline and waxy casts, the two forms being 



MICROSCOPIC EXAMINATION OF THE URINE. 489 

readily differentiated by the fact that the former readily dissolve in 
acetic acid, while the waxy casts are either not affected at all by this 
reagent, or, if so, at least not so rapidly. The latter, moreover, are 
more strongly refractive, to which property their waxy appearance 
is due ; their color is slightly yellow or yellowish-gray, while the 
hyaline casts are colorless and usually very pale and transparent. 

Mode of Examination. — Unless a urine can be examined within 
a few hours after being voided, it is well to add a small amount of 
chloroform, so as to guard against bacterial decomposition. The use 
of conical glasses is rather unsatisfactory, and I find it more con- 
venient to keep the urine in well-stoppered bottles. Preserved with 
chloroform it will keep almost indefinitely. Where a centrifugal 
machine is available the specimen can of course be examined at once. 
As soon as a sufficient amount of sediment has been obtained, a few 
drops are spread out on a slide and examined, uncovered, with a low 
power. It is essential, however, to make use of the flat mirror and 
to avoid a bright light. If this is borne in mind no difficulty what- 
ever will be found in demonstrating even the most hyaline speci- 
mens, though they maybe present in very small numbers. In many 
text-books on urinary analysis the writers speak of the difficulty at- 
tending the search for hyaline casts, and the advice is frequently given 
to color the preparations with a drop of a dilute aqueous solution of 
iodo-potassic iodide, or of some other staining reagent, such as gen- 
tian-violet, picrocarmin, methylene blue, or osmic acid. This is en- 
tirely unnecessary, if the directions just given are strictly followed. 
If a bright light is used, however, I am willing to admit that even 
the most experienced may be unsuccessful in his search. 

For the preservation of mounted specimens the following method, 
devised by Kronig may be employed, though I personally prefer to 
keep the urine itself and to mount a fresh specimen, when necessary. 
A drop of the sediment, best obtained by centrifugation, is spread on 
a cover-glass and allowed to dry in the air. It is then placed in a 
10-per-cent. solution of formalin, for ten minutes, rinsed in water, 
and stained for about ten minutes in a concentrated solution of Sudan 
III, in 70-per-cent. alcohol. The excess of stain is removed by im- 
mersion for one-half to one minute in 70-per-cent. alcohol, when the 
specimen is counterstained with Ehrlich's hsemotoxylin, rinsed in 
water and mounted in glycerin. Evaporation is guarded against by 
ringing the specimen with asphaltum. The tube easts are thus 
stained a more or less pronounced blue, the nuclei of the leucocytes 
dark blue and any fatty granules, or needles oi' tatty acids, that may 
be present, a bright rod. 

True Casts. — 1. Hyaline oasts. — (Fig. 111).) Upoo careful ex- 
amination it will be seen that with rare exceptions the matrix ot* 
hyaline easts is not altogether homogeneous, as small granules may 



490 



THE URINE. 



almost always be detected, imbedded in or adhering to the matrix. 
As these granules may occur in greater or less numbers, hyaline 
casts are spoken of as being finely granular (Fig. 117), coarsely 



Fig. 116. 



^7 S 



v i /y „ — 







Hyaline tube-casts. 



granular, finely dotted, etc. Should true morphologic elements be 
detected, the casts are termed blood-casts, epithelial casts (Fig. 118), 
or pus-casts (Fig. 119). It would be better, however, to add the 
term, hyaline, in every instance, so as to distinguish them from pseudo- 
casts, which consist of these elements entirely, and lack a uniform 



Fig. 117. 




Granular tube-casts. 



matrix. It would thus be proper to speak of hyaline epithelial casts, 
hyaline blood-casts, etc., and to apply the collective term — compound 
hyaline casts — to these various subvarieties. 



MICROSCOPIC EXAMINATION OF THE URINE. 



49 L 



The true nature of these various forms can probably always be 
made out without much difficulty, and even in those cases in which 
the hyaline matrix is apparently concealed beneath cellular elements 
it will usually be possible, upon closer observation, to detect a fine 
boundary -line at some portion of the structure. Not infrequently also 
the end of the cast will be seen to be more or less distinctly hyaline. 

Ftg. 118. 




Epithelial casts. 

In others, again, a hyaline zone may be observed along the sides of 
a central organized thread, so to speak, this being frequently seen in 
specimens which are very broad and long. Should any doubt arise, 
however, a drop of acetic acid is added to a drop of the sediment on 
the slide ; the acid dissolves the hyaline matrix, the organized con- 
stituents are set free, and the differential diagnosis between a pseudo- 
cast and a compound hyaline cast is thus readily established. 

Fig. 119. 





PllS CJlStS. 

The length of hyaline casts may vary greatly. It may scarcely 
exceed its breadth, on the one hand, while on the other, although 
rarely, it may pass through the entire microscopic field. In breadth 
they vary between 0.01 and 0.0^) nun. As a rule, the breadth of a 
east is uniform throughout its entire length, but specimens are not 



492 



THE URINE. 



infrequently observed in which one end tapers off considerably, and 
presents a spirally twisted appearance. This may be so marked that 
the entire cast appears transversely striated. It is generally sup- 
posed that this results from the adhesion of one end of the cast to 
the walls of a tubule, the lumen of which it does not fill, so that the 
free end becomes twisted in the downward course. A dichotomous 
branching of one end is also at times seen in very broad hyaline 
specimens. 

Fig. 120. 




a, Fatty casts, b and c, Blood-casts, d, Free fatty molecules. (Roberts.) 

" Fatty globules are found upon the surface of granular casts 
(Fig. 120), but they also form by themselves short, strongly refrac- 
tive casts, which are often beset all over with needles of fatty crys- 
tals. These, however, are not composed exclusively of fat, but 
probably to some extent of lime and magnesium salts of the higher 
fatty acids and allied compounds, for they are not all soluble in 
ether. They have their origin doubtless in fatty degeneration of 
the renal epithelium " (v. Jaksch). 

Granules of melanin, indigo, and altered blood-pigment may also 
at times be observed in casts ; Riedel regards the occurrence of dark 
brown casts as pathognomonic of fractures. 

2. The waxy casts (Fig. 121) may be divided into two groups — 
true waxy casts and amyloid casts ; but as the latter are not neces- 
sarily indicative of the existence of amyloid degeneration of the kid- 
neys, such a classification is at the present time at least of only 
theoretical interest. They are readily distinguished from the hyaline 
casts by the characteristics mentioned above — i. e., their higher de- 



MICROSCOPIC EXAMINATION OF THE URINE. 



493 



Fig. 121. 



gree of refraction, their yellow or yellowish -gray color, and the fact 
that they are either not attacked at all by acetic acid or only very 
gradually. As a rule, only small fragments are found, but these are 
broader and stouter than the stoutest hyaline casts. Waxy casts 
may also contain cellular elements, crystals, and amorphous mineral 
matter; but, as a rule, such compound casts are not so commonly 
observed as are those of the hyaline variety. From the latter they 
differ furthermore in frequently presenting a cloudy appearance, 
which in some cases is undoubtedly clue to the presence of innumer- 
able bacteria, and it has been suggested 
that these may be directly concerned in 
their production. 

As has just been stated, some waxy 
casts give the amyloidre action ; i. e., 
they assume a mahogany color when 
treated with a dilute solution of iodo- 
potassic iodide, which turns to a dirty 
violet upon the addition of dilute sul- 
phuric acid. It should be remembered, 
however, that this reaction in casts does 
not necessarily indicate the existence of 
amyloid disease of the kidneys, as the 
reaction may be absent on the one hand 
in this condition, and present on the other 
where amyloid degeneration does not ex- 
ist. This curious phenomenon is usually 
explained by assuming that such casts 
have remained in the uriniferous tubules 
for a long time, and have there undergone 
certain chemical changes, analogous to the 
so-called " amyloid metamorphosis " of 
old precipitates of fibrin, and it is indeed 
possible that waxy casts are originally 
hyaline. Frerichs has pointed out that 
fibrin which has remained in the urini- 
ferous tubules for a long time becomes denser and yellowish in ap- 
pearance, which would explain the fact that these casts are only with 
difficulty attacked by acetic acid. 

Before leaving this subject it should be stated that "east-like" 
formations, consisting entirely of amorphous urates, are not infre- 
quently encountered in urines, and according to Leube they may be 
obtained from any urine, if it is concentrated in a vacuum at a tem- 
perature of 37° to 39° C. Students frequently regard such forma- 
tions as coarsely granular easts, an error which may be guarded against, 
if the characteristics of hyaline casts set forth above are borne in mind. 





Different forms of waxy casts; a, 
With a coating of urates." //. Waxy 
cast covered with crystals of oxalate 
of lime, c, Fragments o( waxy 
casts, (v. JAKSCH. I 



494 THE URINE. 

Bacteria (in cases of infectious pyelo-nephritis), hamiatoidin, and 
granular detritus frequently occur grouped in a cast-like manner ; 
their nature is readily ascertained, as in the case of the so-called 
urate casts just described. 

Pseudo-casts, consisting of epithelial cells or blood-corpuscles and 
fibrin, are rarely seen in urinary sediments. The epithelial pseudo- 
casts are probably only seen in cases of desquamative nephritis, and, 
unlike the true casts, are hollow, the epithelium of the uriniferous 
tubules being thrown off en masse. Blood-casts (Fig. 120) consist 
of fibrin, within the meshes of which red corpuscles are generally 
found ; these either present a normal appearance or occur as mere 
shadows, owing to the fact that their haemoglobin has been dissolved. 
Thev are seen whenever extensive hemorrhage has taken place in the 
renal parenchyma, and are far more frequently observed than the 
epithelial pseudo-casts. Hyaline casts are probably always met with 
in urinary sediments in which pseudo-casts are found, and may be 
readily distinguished from the latter, even when beset with numerous 
epithelial cells or red corpuscles (see above). 

Cylinclroids (Fig. 122) resemble hyaline tube-casts somewhat in 
general appearance, but differ from them in being much larger and 
band-like. Like the true casts, they have a uniform breadth, and are 
often beset with crystals and cellular elements, such as leucocytes, 
red corpuscles, and epithelial cells. They are easily dissolved by 
acetic acid, thus differing from the mucous cylinders or pseudo-cylin- 
ders (Fig. 123), which may be observed in any urine containing 
mucus ; the latter probably never contain morphologic or mineral 
constituents, and are never of the same breadth throughout their 
length. The cylindroids proper are undoubtedly of renal origin and 
closely related to the true casts ; formations are indeed not infre- 
quently seen in which a tube-cast terminates in a cylindroid at one 
or both ends (see Fig. 116). 

Formation of Tube-casts. — Several hypotheses have been advanced 
to explain the formation of tube-casts, — reference is here only had to 
true casts, and not to pseudo-casts, the origin of which is sufficiently 
obvious,^and until recently it was quite generally accepted that these 
consist of coagulated albumin which has transuded into the tubules ; 
according to this view a cylindruria would always be indicative of 
the existence of albuminuria. In Xeubauer and "Vogel's Urinary 
Analysis, latest edition (ninth), it is stated that " as to the signifi- 
cance of tube-casts it must be remembered that these, according to 
our present knowledge, consist of albumin, which coagulates under 
the influence of the acid reaction of the urine, in the renal paren- 
chyma, in a peculiar hyaline manner. They merely represent a 
solidified portion of the albumin held in solution by the urine ; their 
elimination essentiallv indicates the existence of an albuminuria." 



MICROSCOPIC EXAMINATION OF THE URINE. 



495 



More recently, however, and probably owing to the reported ab- 
sence of albumin in certain cases of cylindruria, it has been suggested 
that tube-casts are the product of a faulty metamorphosis, or of in- 
flammatory irritation of the renal epithelium, and that a secretion 
from these cells or a disintegration of their protoplasm occurs, result- 



Fig. 122. 



Fig. 123. 




a and b, Cylindroids from the urine in 
congested kidney, (v. Jaksch. ) 



/ I 



y/ 



Mucous cylinde 



ing in the formation of cylindroids or true casts. So far as the ex- 
istence of a eylindruria sine albuminuria is concerned, 1 must confess 
that I am very skeptical as to the actual occurrence of such a condi- 
tion, and I fully agree with Xoubauer and Vogel when they state 
that "whenever the number of tube-easts is minimal the correspond- 



496 THE URINE. 

ing amount of albumin may be so insignificant that it may not be 
demonstrable by means of the ordinary, coarser tests." In several 
thousand examinations I have never seen a true case of cylindruria 
sine albuminuria. It is difficult, moreover, to imagine that an elim- 
ination of blood-casts and others, which, according to Kossler, are 
" frequently " encountered in urines, can take place in the absence 
of a coincident elimination of albumin, as is claimed by him, and 
until further and more convincing evidence is offered in favor of a 
cellular origin of tube-casts, it may be better to regard cylindruria 
as equivalent to albuminuria. 

Clinical Significance of Tube-casts. — Formerly the occurrence of 
tube-casts in the nrine was held to indicate the existence of nephritis. 
This view has been abandoned, however, for the same reasons which 
led to the rejection of the theory that albuminuria invariably indi- 
cates Bright' s disease (see above). 

The statement is frequently made in text-books that tube-casts 
may occur in the urine of perfectly healthy individuals, following 
severe muscular exercise, cold baths, etc., — in short, all stimuli which 
may cause the appearance of albumin in apparently normal individ- 
uals. It has been indicated elsewhere (see Functional Albuminuria), 
however, that such stimuli cannot be regarded as " physiologic " 
in every instance, and the presence of tube-easts in the urine similarly 
should be regarded as a pathologic event. 

It is not necessary in this connection to enumerate the various 
diseases in which cylindruria is observed, as these are the same as 
those which give rise to albuminuria ; and just as a neplir angiogenic 
cdbuminuria is more frequently observed than a nephritidogenic albu- 
minuria, so also is the presence of tube-casts in the urine more fre- 
quently due to circulatory disturbances in the kidneys than to true 
nephritis. In every case in which tube-casts occur in the urine it 
may be assumed that the accompanying albuminuria is, to a certain 
extent at least, of renal origin. 

While the existence of cylindruria is not necessarily associated 
with definite pathologic alterations of the renal parenchyma, this 
statement should be restricted to the occurrence of purely hyaline 
casts, and their presence in only small numbers. A few renal epi- 
thelial cells may be found at the same time, occurring either free in 
the urine or adhering to the casts, but never presenting an atrophic 
or otherwise altered appearance in the absence of definite renal lesions. 
The presence of compound hyaline and coarsely granular casts, as 
well as of waxy and amyloid casts, on the other hand, may probably 
always be regarded as indicating definite changes in structure, so that, 
so far as the diagnosis of nephritis is concerned, a microscopic exam- 
ination of the urine will furnish information of more value than the 
simple demonstration of albumin. 



MICROSCOPIC EXAMINATION OF THE URINE. 497 

Hyaline casts are those most frequently seen, — reference is here had 
only to the purely hyaline or, at least, but faintly granular form, — 
and are found in all conditions in which albuminuria occurs. When 
present in only small numbers, and particularly when occurring but 
temporarily in the urine, it may be assumed, in the absence of other 
symptoms pointing to renal disease, that we are dealing with a mild 
circulatory disturbance of the kidneys. Renal epithelial cells are 
absent, or present only in small numbers. The albuminuria at the 
same time is trifling. If, however, hyaline casts are continuously 
present in large numbers, and if the amount of albumin exceeds a 
trace, the existence of a nephritis may usually be inferred. In such 
cases granular casts and compound hyaline casts, particularly the 
former, will be found, if the nephritis is chronic, while in the acute 
form the hyaline type prevails. Should blood-casts be present at 
the same time, the probabilities are that we are dealing with an acute 
nephritis, or an acute exacerbation of a chronic process ; in the latter 
case coarsely granular casts will also be present in large numbers. 

Waxy casts always indicate a chronic or, at least, a subacute proc- 
ess. The fatty casts described by Knoll and v. Jaksch " are most 
commonly associated with subacute or chronic inflammations of the 
kidney of protracted course, with a tendency to fatty degeneration 
of the renal tissue. Post-mortem examination has shown that they 
form most frequently in cases of large white kidney. In some cases 
in which they were present, however, the organ was found to be 
more or less contracted ; but when this was so, it w T as invariably far 
advanced in fatty degeneration.' 7 

It has been stated that from a careful examination of the renal 
epithelial cells it is often possible to determine whether an inflamma- 
tory process affecting the kidneys is at the same time complicated 
with degenerative changes. As a matter of fact, the cells found on 
the tube casts under such conditions no longer present a normal 
appearance, but are shrunken and atrophied, and in cases of fatty 
degeneration studded with fatty granules. Epithelial casts, in the 
absence of distinct changes affecting the renal parenchyma, arc prob- 
ably never seen. 

The occurrence of pus-casts presupposes the existence ot^ suppura- 
tive inflammation in the kidneys, while the presence of only a small 
number of leucocytes on hyaline casts may be observed in the ordi- 
nary forms of nephritis and particularly in the acute form. 

The pathologic significance of the so-called amyloid easts and 
pseudo-casts has already been considered. 

Cylindroids are present whenever hyaline easts are seen and have 
essentially the same import. They are said to occur most frequently 
in the urine of children. 

So far as the constancy with which tube-easts occur in the urine in 
32 



498 



THE URINE. 



nephritis is concerned, it is well known that in the chronic interstitial 
form of the disease they, as well as albumin, are frequently absent 
for a long time, so that it may only be possible to make the diagnosis 
from the clinical history and the physical signs. It is a well-known 
fact, moreover, that pathologic alterations of the kidneys, particularly 
in men past middle age, are observed again and again in the post-mor- 
tem room, where a previous examination of the urine showed no 
evidence of the existence of renal disease. In the acute and sub- 
acute forms of nephritis, as well as in the ordinary parenchymatous 
form, tube-casts are probably always found, and it would further 
appear that acute circulatory disturbances affecting the renal paren- 
chyma quite constantly lead, not only to albuminuria, but also to 
cylmclruria. 

Spermatozoa. — Spermatozoa, for a description of which the reader 
is referred to the chapter on Semen, are frequently observed in the 

Fig. 124. 




Human spermatozoa. 



urine of healthy adults, and are quite constantly met with in the 
first urine passed after coitus or nocturnal emissions, when their pres- 
ence is, of course, of no significance (Fig. 124). Such urines are 
always cloudy, but it is impossible to recognize the source of the 
turbidity by simple inspection. 

A sediment composed of phosphates is popularly regarded as be- 
ing due to semen, and no doubt every physician has seen patients, — 
usually sexual neurasthenics, — who are greatly alarmed at finding a 
white deposit in the chamber, and who imagine themselves " sufferers 
from loss of manhood." The microscope is necessary in every case 
to determine the presence of spermatozoa. 



MICROSCOPIC EXAMINATION OF THE URINE. 499 

In females semen is found in the urine whenever the external 
genitals have been polluted during or after coitus, as well as in the 
exceptional cases in which connection has been effected by the 
urethra. From a medico-legal standpoint the discovery of sperma- 
tozoa in the urine of women may be of the greatest importance, but 
otherwise it is without significance. 

In a few instances it is stated that trichomonades have been mis- 
taken for spermatozoa. I am convinced, however, that such an error 
can only occur if the observer is totally unacquainted with the sub- 
ject under consideration. 

In pathologic conditions spermatozoa are not infrequently found 
in the urine. In cases of severe constipation, owing to pressure of 
hard scybalous masses upon the seminal vesicles, a partial evacuation 
of semen may occur, which may or may not be accompanied by a 
certain degree of sexual excitement. Horowitz has pointed out that 
a discharge of semen may be noted in cases of periurethral abscess 
with perforation into the ejaculatory ducts, giving rise to spermato- 
cystitis, the condition being due to a tight stricture of the urethra 
with dilatation beyond the constricted portion. I have observed a 
case of cystitis in which spermatozoa could almost always be detected 
in the urine. An operation revealed a tight stricture of the urethra 
and a sacculated bladder ; the constant elimination of semen was ap- 
parently owing to the irritating action of the ammoniacal urine. It 
should be noted that in this case, as well as in those in which semen 
is frequently passed during the act of defecation in the absence of 
sexual excitement, no deleterious effects referable to such loss were 
noted. In the urine voided during and after epileptic and, more 
rarely, hystero-epileptic seizures, spermatozoa may be found. Such 
an event is undoubtedly due to muscular spasm, and is identical in 
origin with the emission of semen observed so frequently after death, 
during strangulation, etc. 

In certain spinal diseases semen may be found in the urine, and 
Fiirbringer relates a most interesting case in which, following frac- 
ture and dislocation of the vertebral column, with partial destruction 
of the middle dorsal cord, spermatorrhoea associated with partial 
erection occurred thirty hours later, and continued until death, which 
took place after three days. 

More important is the loss of semen noted in cases of true spenna- 
torrhoea, due to venereal excesses or masturbation, when spermatozoa 
may be found almost constantly, and the diagnosis indeed will often 
be dependent upon such an observation. 

So far as the question of sterility in the male is concerned, reliance 
should not be placed upon an examination of the urine, but the semen 
should he obtained as soon as possible after coitus, and examined as 
indicated elsewhere (see |>. 526). 



500 THE URINE. 

Parasites. — Vegetable Parasites. — It has been shown by numerous 
investigations that bacteria are always present both in the male and 
female urethra, and that they may at times gain entrance to the 
bladder. The weight of evidence, however, is in favor of the view 
that the urine intra vesicam is under normal conditions free from 
micro-organisms, and that any bacteria which may have found their 
way into the bladder are rapidly killed in healthy individuals. In 
every urine, on the other hand, that has been exposed to the air, 
bacteria are always present. Whenever, then, it is desired to deter- 
mine whether or not the urine of the bladder contains micro-organ- 
isms, every precaution should be taken to guard against accidental 
contamination. To this end the following method should be em- 
ployed : If the patient is a male, he is instructed to hold his urine 
until a fairly large amount has accumulated. The glans is then 
thoroughly washed with soap and water and further cleansed with 
cotton soaked in bichloride solution (1 : 1000). The fossa navicularis 
is also thoroughly cleansed with the same solution. The urine is then 
voided under as great pressure as possible. The first portion (about 
100 c.c.) is thrown away, and the second received in a sterilized 
vessel, when cultures should be made at once, agar or gelatin plates 
being inoculated with 1 or 2 c.c. of the urine. In the female the 
vulva is cleansed with soap and water, and the urethral aperture dis- 
infected with bichloride solution. After then washing with sterilized 
water and drying with sterilized cotton the urine is evacuated through 
a sterilized metallic or glass catheter, and received in a steriliz'ed vessel. 
Among the bacteria which may be found in 
Fig. 125. every urine that has been exposed to the air the 

C"* \-P micrococcus urece is of special interest, as ammo- 



v ^ 



\z 



*°%s 



> niacal fermentation is largely due to its presence. 

/V>- *i"*V<r"* ? When fermentation has commenced it is readily 

recognized, occurring in almost pure culture upon 



■V* 



the surface of the urine, mostly in the form of 
Micrococcus ure*. characteristic chains (Fig. 125). The individual 
coccus is colorless and quite large, so that it may 
be mistaken by the beginner for a blood-shadow. 

It is a common error to infer from the occurrence of ammoniacal 
decomposition very soon after micturition, that this process has al- 
ready began in the bladder. It should be remembered that urine 
may undergo fermentation, particularly in warm weather, shortly 
after having been voided, and especially if the vessel employed is 
not absolutely clean, and the urine has been allowed to stand exposed 
to the air. The diagnosis of ammoniacal fermentation in the bladder 
should hence only be made when the presence of ammonia can be 
demonstrated in the urine immediately upon being voided. 

Under pathologic conditions various pathogenic bacteria may be 



MICROSCOPIC EXAMINATION OF THE URINE. 501 

found in the urine. Their presence usually indicates the existence 
of definite changes in the renal parenchyma, although these changes 
are not necessarily of an inflammatory character. Pyogenic cocci 
are especially prone to settle in the kidneys, and there give rise to 
focal inflammations, but even in the absence of such lesions they are 
frequently found in the urine. In all forms of infectious nephritis 
an abundant elimination of bacteria may generally be observed, v. 
Jaksch states that in erysipelas the bacteriuria and nephritis disap- 
pear, together with the cessation of the disease, and in various suppu- 
rative processes, taking place in the body, the specific bacteria disap- 
pear from the urine within twenty-four to forty-eight hours after the 
evacuation of the pus. 

Most interesting observations on the occurrence of bacteria in the 
urine of nephritic patients have been reported by Engel. Thirty- 
one cases were examined. In sixteen the staphylococcus albus and 
aureus was found, in eight pyogenic streptococci, in four the tubercle 
bacillus, in five the bacillus coli communis and in one the typhoid 
bacillus, while negative results were obtained in only two instances. 
In the same series Engel also found a pyogenic coccus in seventeen 
cases. This coccus was larger than the known forms ; it could be 
stained according to Gram's method, and did not liquefy gelatin. 
Intravenous injections of large numbers of the organism caused 
nephritis in rabbits. 

In pneumonia and pneumococcus infections in general, the corre- 
sponding diplococcus may be found, and in erysipelas and strepto- 
coccus infections streptococci. Fairly constant is the presence of 
the bacillus coli communis in cases of pyelonephritis ; it is usually 
found in pure culture, but is at times associated with the staphy- 
lococcus aureus and the proteus Hauser. In some instances the 
latter organism has also been met with in pure culture. Of great 
interest further is the frequent occurrence of the typhoid bacillus 
in the urine of typhoid fever patients. Bouchard in 1881 already 
drew attention to the elimination of the bacillus through this 
channel, and stated that he was able to demonstrate its presence in 
fifty per cent, of his typhoid fever cases. Other observers were less 
successful, but with improving technique and more general investi- 
gation a larger number of positive results is being obtained from year 
to year. At the present time it may be said that the typhoid bacillus 
can be found in the urine of typhoid fever patients in from 20—30 
per cent, of all cases. ■ They usually appear in the second or third 
week of the illness and may persist for months and even years. 
When present they usually occur in pure culture, and are often 90 
numerous as to render a freshly voided specimen ot" urine cloudy. 
Symptoms of cystitis and marked renal involvement often exist, but 
in a considerable number of eases there are no indications ot' local 



502 THE URINE. 

disease. Their elimination in the urine is of no prognostic signifi- 
cance, but important from the standpoint of prophylaxis. They may 
be isolated and identified according to the usual methods (see p. 237). 

Very important further is the fact that in tubercular disease of the 
urinary organs tubercle bacilli may be found in the urine. The 
search for them, however, is frequently fruitless and always tedious. 
In suspected cases it is best to centrifugate the urine, and to spread 
the sediment upon slides or cover-glasses. The preparations are then 
fixed by heat, and best stained with Pappenheim's reagent (see p. 
265). The usual methods of staining are not admissible, as the 
smegma bacillus, which may also be present in the urine, is likewise 
stained, and could readily be mistaken for the tubercle bacillus. 
Grethes method which was formerly used to differentiate the two, is 
less reliable. Following this method the specimens are stained with 
a concentrated alcoholic solution of fuchsin, the staining fluid being 
brought to the boiling point on the slide. They are then washed in 
water and counterstained with a concentrated alcoholic solution of 
methylene blue without the application of heat. The excess of stain 
is washed off, when the preparations are dried with filter-paper and 
examined as usual. As with Pappenheim's method the tubercle 
bacilli are colored red, while the other morphologic elements, which 
may be present, including the smegma bacillus, are stained blue. 

If, in suspected cases, notwithstanding repeated examination, and 
the preparation of numerous specimens, tubercle bacilli are not found, 
it is best to inject a few drops of the sediments into the anterior 
chamber of the eye of a rabbit, and to watch for the development of 
miliary tubercles in the iris. 

The number of bacilli which may be found in the urine in tuber- 
cular diseases of the urinary organs is extremely variable. Fre- 
quently none at all are found, notwithstanding the most careful 
search; in other cases they are present in small numbers, while in 
still others they are extremely numerous, and then often bunched 
together to form particles which are visible with the naked eye. 

Isolated tubercle bacilli have also been found in the urine in cases 
of acute miliary tuberculosis, in the absence of renal changes ; such 
observations, however, are uncommon. 

The gonococeus of Neisser is rarely found free in the urine, but 
for sake of convenience is described at this place. The organism 
(Plate XVIII.) occurs in the form of small, oval, or round granules, 
usually grouped in twos and fours, resembling a German biscuit or 
the figure 8. As a rule it is found enclosed within pus-corpuscles 
and epithelial cells, but it may also occur free in the pus obtained 
from the urethra, in the vaginal discharge and more rarely in uri- 
nary sediments, as in cases of complicating prostatitis, peri-urethritis, 
etc. In cover-glass preparations account should only be taken of 



PLATE XVIII. 







: .'•'- * "' 


: i 




*£| 


t . gp, 


#->> ^ 

^ 


«* * '-"''I. 




- pi o 




X. ;;» «£ 




• * •*.* 




i 


. SCHMIDT, FEC 



Urethral Discharge from a Case of Gonorrhoea, showing Gonoeoeei Enclosed in 

Pus Corpuscles, and Lying Free in the Discharge. Stained with 

Methylene Blue. (Personal Observation.) 



MICROSCOPIC EXAMINATION OF THE URINE. 503 

those organisms which are enclosed within cellular elements, as these 
alone can be regarded as characteristic. To this end a drop of the 
discharge is spread in a thin layer upon a slide or cover-glass, dried 
in the air and fixed by passing through the flame of a Bunsen burner 
three or four times. The specimens may then be stained with any 
one of the basic anilin dyes. In my laboratory Jenner's stain is now, 
almost exclusively, used for this purpose (see p. 89). The organ- 
isms are thus colored blue, while the granules of the eosinophilic 
leucocytes, which are so commonly present at the same time, appear 
a bright red, or a brownish-red. After five minutes the excess of 
stain is washed off, when the preparations are rinsed in water, dried 
with filter paper and examined with a high power. 

Of special interest is the observation of Unna and Plato, that the 
gonococcus can be stained in the living leucocyte with Ehrlich's neutral 
red. The method employed is very simple. A small drop of the fresh 
pus is mixed with an ease of a dilute solution of neutral red in nor- 
mal salt solution (1 c.c. of a saturated aqueous solution to 100 c.c), 
and examined, either as hanging drop or mounted on a slide, as usual, 
Thus prepared, a certain number of the intracellular gonococci are 
stained a deep red, while others are not stained, and it may be ob- 
served, on warming the slide, so as to elicit amoeboid movements, 
that some of the gonococci which w T ere stained so long as they re- 
mained within the granular portion of the leucocytes, are gradually 
decolorized when they come to lie in the homogeneous ectosarc, and 
are colored again on returning to the granular protoplasm. Plato 
states that he has examined numerous other intracellular organisms, 
including pseudo-gonococci, but that he has never observed as rapid 
and intense staining as with the true gonococci. He therefore sug- 
gests that with neutral red it may be possible to differentiate the gono- 
coccus from similar organisms. Extra-cellular gonococci, as well as 
numerous other bacteria are not stained, even after an exposure of 
several days. 

When no discharge can be obtained from the urethra, or an exami- 
nation of such discharge is negative, positive results may at times 
still be obtained, if some of the gonorrhoea! threads, which may be 
found floating in the urine, are examined. In these the organisms 
can occasionally be demonstrated after months and even years have 
elapsed since the time of infection. 

In doubtful cases, and especially in women and children, cultures 
should be made, as the organisms may be confounded with pseudo- 
gonococci, which are frequently present both in the diseased and 
normal urethra of males and females. The organism grows host on 
a mixture of human blood-serum and nutrient agar (1:2 or 3 parts). 
The surface colonies are pale, grayish, translucent, finely granular, 
with finely notched borders. In bouillon and blood-serum mixed. 



504 THE URINE. 

it forms a membrane, while the fluid remains clear. On agar the 
organism does not grow. Like the pseudo-gonococci the gonococci 
cannot be stained by Gram's method. 

In cases of cystitis a large variety of micro-organisms has been 
met with in the urine. Among the more important may be men- 
tioned the staphylococcus aureus, albus and citreus, streptococci, 
the bacillus coli communis, the bacillus pyocyaneus, the bacillus of 
typhoid fever, the proteus Hauser, etc. In many cases of cystitis 
organisms are, moreover, found, which are apparently non-patho- 
genic, and are capable of causing the formation of sulphuretted 
hydrogen from certain sulphur bodies of the urine (see Hydrothio- 
nuria). 

Actinomyces kernels may be observed in the urine, when the 
disease in question has attacked the genito-urinary tract, or when 
they have found their way into the urine from other organs. 

In conclusion, reference should be made to the occasional occur- 
rence of a certain form of bacteriuria, which is not associated with 
any pathological process, and has hence been termed idiopathic 
bacteriuria. Of its causation and significance nothing is known, but 
it is possible that in these cases a few bacteria enter the bladder either 
through the anterior rectal wall, or are eliminated through the kid- 
neys from the blood current. Finding a suitable medium for their 
growth in the urine they here multiply and may thus be constantly 
present. Of late the bacillus lactis aerogenes has been found in such 
a case. The diagnosis " idiopathic bacteriuria " should of course 
only be made, if every possible source of contamination of the urine 
can be definitely excluded. 

Urines containing bacteria in large numbers are always cloudy 
and usually present an acid reaction, when voided, unless a cystitis 
exists at the same time. Attention will be directed to their presence 
by the fact that such specimens cannot be cleared by simple 
filtration. 

Yeast-cells in large numbers are usually only seen in urines con- 
taining sugar. Whenever a chemical examination has not been made, 
their demonstration will be of importance, as suggesting the possible 
existence of glycosuria. 

Moulds are usually seen in old diabetic urines after alcoholic fer- 
mentation has taken place, but may also occur, though far less fre- 
quently, upon the surface of putrid urines that have contained no 
sugar. 

The urinary sarcina, which is at times met with, is smaller than 
the sarcina of the gastric contents, but closely resembles it in appear- 
ance. It is of no clinical significance. 

Whenever a urine is to be examined bacteriologically, special pre- 
caution should be taken to guard against its accidental contamination. 






MICROSCOPIC EXAMINATION OF THE URINE. 505 

The safest procedure, of course, is to obtain the urine by supra-pubic 
puncture. This is, however, only exceptionally necessary, and as a 
general rule the method of disinfection, which I have described 
above (see p. 500) will be sufficient. 

Animal Parasites. — The organism which Hassal saw in a urine 
that had been " freely exposed to the air" and was alkaline, and 
which he termed Bodo urinarius, was in all probability an infuso- 
rial monad and of no pathologic significance. Salisbury was the first 
to point out that the trichomonas vaginalis of Donne* may at times 
occur in the bladder, but gave no detailed account of his cases. 
Kunstler, Marchand, Miura, and Dock then reported cases in which 
flagellate protozoa were found, and modern research leaves no doubt 
that the organisms described by these observers are identical with the 
trichomonas of Donne. In Miura's case the habitat of the parasite 
was the urethra, and an examination of the patient's wife revealed 

Fig. 126. 









,' r W. 
A gonorrheal thread. 

the presence of similar organisms in the vagina. Kunstler's ease 
was one of pyelitis following cystotomy. Marchand' s patient had 
a fistula in the perineum following suppuration in the pelvis of un- 
known origin ; cystitis did not exist. Dock's case was associated 
with hsematuria. During the past four years I have seen the same 
organism in six cases, two of which I owe to the kindness of Dr. W. 
M. Lewis of Baltimore. Five were females, and I have no doubt 
that the parasite found its way into the bladder from the vagina, 
where it could be demonstrated in two instances. 

Curiously enough a history of hsematuria was obtained from three 
of the six patients. In one case the urine contained blood at the 
time of the examination. Evidence of nephritis or well-marked cys- 
titis did not exist. The number of the parasites was very variable. 
but in four cases quite large. 

Balz observed numerous amoebae in the turbid urine of a girl, the 



506 THE URINE. 

subject of phthisis, which he described as being of larger size than 
the amoeba coli. Ciliated infusoria have also been found in the 
urine in isolated cases. 

The ova of distoma haematobium and the filaria sanguinis hominis 
are at times found in the urine, their elimination being usually 
accompanied by hsematuria and chyluria. Echinococcus hooklets 
and fragments of cysts may also be found, and in rare instances 
ascarides find their way into the urinary passages when a fistulous 
opening exists between the rectum and the bladder. Bothrioceph- 
alus linguloides, Leuckart, was found in the urine in one case occur- 
ring in Eastern Asia. Eustrongylus gigas is likewise found very 
rarely. Moscato records one case in which chyluria existed at the 
same time. In Dr. Clark's case, which was recently reported in this 
country, the elimination of the worni was accompanied by hsema- 
turia. 

Tumor-particles. — Tumor-particles are so rarely seen in the urine 
that a detailed account of their occurrence may be omitted, particu- 
larly as it is seldom possible to base the diagnosis of tumor upon the 
presence of fragments in the urine, the clinical history and the 
physical signs being usually sufficient to reach a satisfactory diagnosis. 

Foreign Bodies. — Among foreign bodies which may be found in 
the urine may be mentioned particles of fat, fibres of silk, linen, and 
wool, etc. ; in short, material the presence of which is owing to the 
use of unclean vessels for the reception of the urine. Fecal matter 
may be passed by the urethra ; such an occurrence, of course, always 
indicates the existence of an abnormal communication between the 
bowel and the urinary passages. Hair derived from a dermoid cyst 
may similarly be found. In hysteria foreign bodies of almost any 
kind may be shown the physician as having been passed in the urine, 
such as hair, teeth, fish-bones, wood, etc., and even snakes and frogs. 
I had occasion to examine " gravel " " passed " from time to time by 
a hysterical patient in large amounts, "every attack being accompanied 
by the most agonizing pains shooting down into the lower abdomen "; 
the gravel upon examination proved to be mortar, obtained from the 
cellar of the patient's house. 



CHAPTER VIII. 
TKANSUDATES AND EXUDATES. 

DEFINITION. 

In health, the so-called serous cavities of the body contain but 
very little fluid, and quantities sufficient for analytical purposes can 
normally only be obtained from the pericardial sac. In pathologic 
conditions, on the other hand, large accumulations of fluid may be 
observed, not only in the serous cavities, but also in the areolar connec- 
tive tissue, beneath the skin, and beneath the muscles. When due 
to circulatory disturbances, a hydrsemic condition of the blood, or an 
insufficient elimination of water through the kidneys, such accumu- 
lations of fluid are spoken of as transudates, while the term exudates 
is applied to similar accumulations of inflammatory origin. 

Clinically, it is frequently difficult to distinguish between trans- 
udates and exudates, and large ovarian, pancreatic, and hydatid cysts, 
as well as cystic kidneys, may at times be mistaken for ascites. In 
such cases a careful chemical and microscopic examination of the 
fluid in question may be of decided value. Very frequently, more- 
over, it is possible only in this manner to determine the true nature 
of the disease, and the importance of freely using the trocar and the 
aspirating -needle in diagnosis cannot be too strongly advocated. 

TRANSUDATES. 

General Characteristics. 

Transudates are usually serous in character, when they present a 
light-straw color; at times, however, owing to an admixture of blood, 
they have a reddish tinge, and are then said to be sanguineous : in 
rare instances they are chylous. 

The Specific Gravity. 

The specific gravity varies somewhat according to the origin of 
the fluid, but is usually lower than thai of serous exudates occurring 
in the same cavities — one of the most important points of difference 
between the two kinds of fluid. Thus, in acute pleurisy the specific 
gravity of the exudate is usually higher than 1.020, and in chronic 
pleurisy, if an accumulation of pus exists at the same time, higher 

507 



508 



TRANSUDATES AND EXUDATES. 



than 1.018, and may even reach 1.030. In transudates into the 
pleural cavity, on the other hand, referable to circulatory disturb- 
ances, for example, as in cases of hepatic cirrhosis or cardiac insuffi- 
ciency, the figures obtained are usually lower than 1.015. Transudates 
of peritoneal origin similarly present a specific gravity varying between 
1.005 and 1.015, while that of exudates frequently reaches 1.030. 

As the chemical composition, in so far as the mineral constituents 
and extractives are concerned, is practically the same in both classes 
of fluid, the difference in the specific gravity appears to be essentially 
due to the amount of albumin present, viz, serum-albumin and se- 
rum-globulin. It may be demonstrated, as a matter of fact, that 
exudates contain far more albumin than transudates, the amount 
varying between 4 and 6 per cent, in the former, as compared with 
1 and 2.5 per cent, in the latter. The largest amounts of albumin 
in transudates are found in those of pleural origin, while in oedema 
not more than 1 per cent, is usually present. 

In the table below, taken from Reuss, the relation between the 
percentage-amount of albumin and the corresponding specific gravity 
is shown. Reuss suggests the following formula for the purpose 
of determining the amount of albumin in transudates and exudates 
from the specific gravity : 

E = f (S — 1000)— 2.8, 

in which " E " indicates the percentage-amount of albumin and " S " 
the specific gravity, taken by means of an accurate urinometer. 



ific gravity. 


Albumin. 


Specific gravity. 


Albumin 


1.008 . 


. 0.2 


1.019 . 


. 4.3 


1.009 . 


. 0.6 


1.020 . 


. 4.7 


1.010 . 


. 1.0 


1.021 . 


. 5.1 


1.011 . 


. 1.3 


1.022 . 


. 5.5 


1.012 . 


. 1.7 


1.023 . 


. 5.8 


1.013 . 


. 2.1 


1.024 . 


. 6.2 


1.014 . 


. 2.5 


1.025 . 


. 6.6 


1.015 . 


. 2.8 


1.026 . 


. 7.0 


1.016 . 


. 3.2 


1.027 . 


. 7.3 


1.017 . 


. 3.6 


1.028 . 


. 7.7 


1.018 . 


. 4.0 







The following table shows the percentage-amount of albumin ob- 
tained byRuneberg in ascitic fluid under various pathologic conditions: 



Average. Maximum. Minimum. 

Hydremia ( Bright' s disease, tuberculosis, 

etc., with amyloid degeneration) . 0.21 0.41 0.03 

Portal stasis ( referable to hepatic cirrhosis 

or stenosis) . . • . .0.97 2.68 0.37 

General venous stasis ( referable to or- 
ganic heart disease) . . . .1.67 2.30 0.84 

Carcinoma of the peritoneum (compli- 
cated with carcinoma of the stomach). 3.51 5.42 2.70 

Chronic peritonitis (one case complicated 

with heart disease) . . . .3.71 4.25 3.36 



TRANSUDATES. 509 

The fact, moreover, that transudates do not coagulate sponta- 
neously, in the absence of blood, may further serve to distinguish 
these from exudates, in which a coagulum is frequently observed 
after having stood for twenty-four hours. But not much reliance 
should be placed upon this point of difference, as exudates likewise 
do not always coagulate, and clotting of transudates in the presence 
of blood may already take place within the body. 

The Chemistry of Transudates. 

An idea of the chemical composition of the various forms of 
transudates may be formed from the following tables, taken from 
Hoppe-Seyler and Hammarsten, the figures corresponding to 1,000 
parts by weight of fluid ; the specimens were taken from one 
individual : 

Pleura. Peritoneum. ta^SSt* 

Water .... 957.59 967.68 982.17 

Solids .... 42.41 32.32 17.83 

Albumin .... 27.82 16.11 3.64 

Ethereal extract ] 5.27 0.50 

Alcoholic extract ") 3.71 

Aqueous extract f- . 14.59 ! 10 94 1A0 

Inorganic salts f 9.00 

Errors of analysis J J 0.12 

Analysis of Hydrocele Fluid. 

Water 938.85 

Solids 61.15 

Fibrin (formed) 0.59 

Globulins 13.52 

Serum-albumin 35.94 

Ethereal extract 4.02 

Soluble salts 8.60 

Insoluble salts ........ 0.66 

Sodium chloride . . . . . . . . 6.19 

Sodium oxide ........ 1.09 

Sugar and uric acid in small amounts are also, as a rule, found in 
transudates, and in one case of hepatic cirrhosis Moscatelli succeeded 
in demonstrating the presence of allantoiu. 

Microscopic Examination. 

Upon microscopic examination only a few isolated leucocytes, and 
endothelial cells derived from the serous surfaces and undergoing 
fatty degeneration are usually seen. Mast-cells and eosinophilic 
leucocytes have been observed in the ascitic fluid in eases of myeloge- 
nous leukaemia. Charcot-Leyden crystals were present at the same 
time. In cases in which the transudates have been confined for a 
long time plates of cholesterin are frequently ton ml. They are 
especially abundant in hydrocele fluid. 



510 TRANSUDATES AND EXUDATES. 

EXUDATES. 

Exudates may be serous, serofibrinous, sero-purnlent. purulent, 
putrid, hemorrhagic, chylous, or chyloid, terms which do not require 
further definition. 

The purulent, sero-purulent. and putrid forms are manifestly of in- 
flammatory origin, while it may at times be difficult to decide the 
true nature of serous, sero-fibrinous, and sero-sanguineous fluids. In 
such cases the poiuts of difference already described between trans- 
udates and exudates should be borne in mind, and will, when taken 
in conjunction with the physical signs and the clinical history, gener- 
ally lead to a correct diagnosis of the origin of the fluid. 

Serous Exudates. 

Serous exudates are clear, of a light-straw color, and present a 
specific gravity usually exceeding 1.008. After standing, a white, 
fibrinous coagulum is generally formed. Upon microscopic exami- 
nation some red corpuscles, which are probably referable to the punc- 
ture, polynuclear leucocytes, and endothelial cells undergoing fatty de- 
generation are found. Such exudates, as indicated, differ from the 
corresponding transudates in presenting a higher specific gravity, and 
in the fact that clotting is observed in transudates, only in the presence 
of blood. Exudates, however, do not invariably coagulate, and too 
much importance should hence not be attached to this point. 

Hemorrhagic Exudates. 

Hemorrhagic exudates are essentially sero-fibrinous in character, 
the exact color depending upon the amount of blood-pigment present. 
Microscopic examination reveals the presence of a large number of 
red corpuscles, polynuclear leucocytes, and endothelial cells. Choles- 
terin crystals may also at times be seen, though rarely in very large 
numbers. When numerous, attention is readily drawn to them, dur- 
ing the macroscopic examination of the fluid, by the peculiar glisten- 
ing appearance of its surface. 

Tuberculosis. — As hemorrhagic exudates are most commonly 
observed in cases of tuberculosis and of carcinoma of the lungs and 
pleura, the specimen should be carefully examined for tubercle bacilli 
and cancer cells. In every case it will be best to subject portions of 
the fluid to centrif ligation and to examine the sediment thus obtained. 
Usually tubercle bacilli are not found, even when tuberculosis of the 
pleura exists. If in such cases culture-experiments likewise prove 
negative and cancer-cells are not found, the diagnosis of probable 
tuberculosis will nevertheless be warrantable. 

Cancer. — The diagnosis of cancer should be based upon the 
demonstration of cancer-cells in the fluid. The physician, however, 



EXUDATES. 511 

is warned not to mistake endothelial cells for cancer-cells. The 
diagnosis should hence only be made when large epithelial cells of 
variable form, measuring at times 1 20 ju in diameter, are found in 
large numbers, especially when arranged in groups, unless, indeed, 
cancerous nodules presenting the characteristic alveolar structure are 
at once found. Quincke has drawn attention to the occurrence of 
large numbers of fat-droplets, which may attain a diameter of from 
40 fi to 50 fi in the fluid in cases of neoplasm. At times these fat- 
droplets are so small and numerous as to give a chylous appearance 
to the exudate. At other times a similar appearance is due to the 
presence of minute albuminous granules, which may be readily dis- 
tinguished from the former by their insolubility in ether. The 
occurrence of numerous fatty-acid crystals arranged in groups should 
likewise be regarded as favoring the diagnosis of carcinoma. It is 
also claimed by Quincke that carcinoma probably exists, if a marked 
glycogen reaction can be obtained in the endothelial cells. This test 
has already been described in the chapter on Blood (see p. 49). 

Rieder has lately called attention to the occurrence of cells under- 
going division, their nuclei presenting atypical karyokinetic figures, 
which he regards as pathognomonic of carcinoma. Coverslip prep- 
arations are prepared from the sediment, dried in the air, fixed by 
immersion, for an hour, in a mixture of equal parts of absolute alcohol 
and ether, and stained with a dilute solution of hematoxylin. 

Putrid Exudates. 

Putrid exudates are observed following the perforation of a gan- 
grenous focus or of a gastric or intestinal ulcer into one of the body- 
cavities. At other times they are encountered in cases of neoplasm 
and at times even without any apparent cause. The material ob- 
tained in such cases presents a brown or brownish-green color, and 
emits an odor which in itself indicates the character of the exudate. 
Microscopically cholesterin, hsematoidin, and fatty-acid crystals, as 
well as degenerating leucocytes, are found. In cases in which aspi- 
ration of a higher intercostal space reveals the presence of serous 
fluid, while putrid material is obtained at a lower point, the existence 
of a subphrenic abscess should be suspected. In such cases a pure 
culture of the bacillus coli communis has been obtained. The re- 
action of putrid exudates is usually alkaline, but an acid reaction 
may be obtained in cases of perforation of a gastric ulcer; the sar- 
cina ventriculi and saccharomyces may then also be found. 

Pus. 

General Characteristics of Pus. — If pus, which usually presents a 
color varying from yellowish-gray to greenish-yellow. i> allowed to 



512 



TRANSUDATES AND EXUDATES. 



stand for some time, a liquid gradually appears at the top, and in- 
creases in amount, until it is finally possible to distinguish two dis- 
tinct layers, the one above — the pus-serum, the other at the bottom 
— the pus-corpuscles. Upon the number of the latter the consistence 
as well as the specific gravity of the pus is dependent. This may 
vary between 1.020 and 1.040, with an average of 1.031 to 1.033. 
Fresh pus has always an alkaline reaction, which may become neutral 
or slightly acid upon standing, owing to the development of free 
fatty acids, glycerin-phosphoric acid, and lactic acid. The color of 
pus-serum may be a light straw, a greenish, or a brownish-yellow. 
The Chemistry of Pus. — The chemical composition of pus-serum 
and pus-corpuscles may be seen from the following tables : 

Analysis of Pus-serum. 





I. 


II. 


Water ...... 


913.7 


905.65 


Solids ...... 


86.3 


94.35 


Albumins 


63.23 


77.21 


Lecithin ...... 


1.50 


0.56 


Fat 


0.26 


0.29 


Cholesterin ..... 


0.53 


0.87 


Alcoholic extract . 


1.52 


0.73 


Aqueous extract 


11.53 


6.92 


Inorganic salts .... 


7.73 


7.77 


Analysis of Pus-cori 


3 USCLES. 






I. 


II. 


Albumins ...... 


137.62 
342.57 




Nuclein ....... 


T 673.69 

t 685.85 


Insoluble matter . 


205.66 
143.83 




Lecithin ") 

Fat f ••.••• 


J " 75.64 

I 75.00 


Cholesterin 


74.0 


72.83 


Cerebrin ...... 


51.99 \ 

44.33/ 




Extractives ...... 


101.84 



Peptone is usually present, and derived from the pus-corpuscles. 
Leucin and tyrosin are likewise frequently met with in the pus of old 
abscesses, and fatty acids, urea, sugar, glycogen, biliary pigments, 
and acids (in catarrhal jaundice), acetone, uric acid, several xanthin 
bases, cholesterin, etc., have occasionally been observed. 

Microscopic Examination of Pus. — Leucocytes. — If a drop of pus is 
examined with the microscope, it will be seen to contain innumerable 
leucocytes, the diameter of which varies from 8 ;i to 10 fi, and which 
in fresh pus exhibit amoeboid movements. It is curious to note that 
the so-called lymphocytes do not occur in pus, and even in the rare 
cases in which a predominance of this variety is met with in the 
blood, as in cases of lymphatic leukaemia, only the larger forms occur 
in the pus of abscesses which may have formed. While the leuco- 
cytes of fresh pus usually present a normal appearance, specimens 



EXUDATES. 513 

may be observed in which amoeboid movements can no longer be ob- 
served, even upon the application of heat, and in which rounded 
vacuoles, filled with a clear liquid, and fatty granulations in moderate 
numbers, may be seen. A predominance of such dead leucocytes 
usually indicates that the pus is old or has been formed in greatly 
debilitated subjects. 

Owing to a resorption of water from accumulations of pus of long 
standing such material finally assumes a caseous aspect, and the 
leucocytes will be seen to have greatly diminished in size, and to 
have assumed an angular, shrunken appearance ; it is then hardly 
possible to demonstrate the presence of a nucleus, even after the ad- 
dition of acetic acid. 

It is noteworthy that in cases of hepatic abscess referable to the 
amoeba coli it is seldom possible to demonstrate any normal leuco- 
cytes, and it will be seen that under such conditions the pus consists 
essentially of granular and fatty detritus, while in liver-abscesses 
due to other causes the leucocytes usually present a fairly normal 
appearance. 

In gonorrhoeal pus eosinophilic leucocytes are frequently found. 
Dr. E. Owings, who studied this question in my laboratory, Avas led 
to the following conclusions : 

1. Eosinophilic leucocytes are present in the gonorrhoeal pus in a 
large percentage of cases. They may be absent, however, even when 
a marked hyperleucocytosis and eosinophilia exist in the blood. 

2. Their number varies pari passu with the number present in the 
blood, and the percentage in the pus is never in excess of the per- 
centage in the blood. 

3. Gonococci are rarely found in eosinophilic leucocytes. 

As has already been pointed out, eosinophilic leucocytes are also 
found in the sputum, and are especially abundant in cases of bron- 
chial asthma and emphysema. 

Mast-cells are only exceptionally seen in pus. 

Giant Corpuscles. — So-called giant pus-corpuscles, measuring 
at times from 30 ;i to 40 fx in diameter, have been observed in ab- 
scesses of the gum, hypopyon, and in the contents of suppurating 
ovarian cysts, but do not appear to have any special significance. 
Upon careful examination these bodies will be seen to contain one 
oval nucleus, usually located eccentrically within the cell, and Prom 
one to thirty or even forty pus-corpuscles. 

DETRITUS. — Fatty and albuminous detritus in variable amount 
may be observed in every specimen of pus, and increases with the 
length of time that it has been confined within the body. The same 
holds good for the presence of free nuclei, which were formerly re- 
garded as young pus-corpuscles, hut which have now been definitely 
recognized as originating during the disintegration of the corpuscles. 
33 



514 TRANSUDATES AND EXUDATES. 

Red Corpuscles. — Red blood-corpuscles in variable numbers are 
usually seen in every specimen, their appearance depending upoD the 
length of time that they have been confined. Pus- corpuscles may at 
times be seen to contain a red corpuscle. 

In doubtful cases it is always well to search carefully for the 
presence of tissue-elements, as it is at times possible, only in this 
manner, to recognize the true character of the morbid process. As 
the data of importance have already been detailed in other sections 
of this book (viz, Sputum and Urine), it will be unnecessary to re- 
capitulate at this place. 

Pathogenic Vegetable Parasites. — Among the pathogenic 
organisms which are of especial interest from a clinical standpoint 
there may be mentioned the true pus-organisms, notably the staphy- 
lococcus pyogenes aureus and the streptococcus pyogenes ; further- 
more, the tubercle bacillus, the actinomyces hominis, the bacillus of 
glanders, the bacillus of anthrax, leprosy, tetanus, influenza, and 
FrankePs pneumococcus, etc. The majority of these have already 
been described, and the reader is referred for more detailed infor- 
mation to special works on bacteriology. In this connection it will 
suffice to state that, so far as pleural exudates are concerned, an ab- 
sence of micro-organisms is usually indicative of tuberculosis, while 
the presence of Franker s pneumococcus in exudates forming in the 
course of a pneumonia appears to be a favorable omen, as regards the 
origin of the pleuritic effusion. 

Protozoa, with the exception of the amoeba coli, have only rarely 
been found. Kiinstler and Pitres observed numerous large spores 
with from ten to twenty crescentic corpuscles in the pus taken from 
the pleural cavity of a man, which closely resembled the coccidia 
of mice. Litten observed cercomonads in the fluid withdrawn from 
a pleural cavity. Trichomonads have been found in a case of 
empyema. 

Most important in this connection is the demonstration of the 
amoeba coli in the pus, and in cases of liver-abscess an examination 
with this view should never be neglected, as the prognosis will to a 
large extent depend upon the results obtained. So far as the occur- 
rence of amoebae in pus is concerned, the observation of Flexner, 
who demonstrated their presence in an abscess of the lower jaw, 
shows that they should not be looked for in the pus of abscesses of 
the liver or lung only. 

Vermes. — Of these, the filaria and hydatids are very rarely ob- 
served in this country. Bothriocephalus leguloides has been found 
in the pleural cavity of a Chinese patient. 

Crystals. — As has been stated, crystals of cholesterin are fre- 
quently found in old pus and in exudates of long standing, but are 
rarely seen in recent exudates. They may be recognized by their 



EXUDATES. 515 

characteristic form and their chemical reactions, as described in the 
chapter on Feces (p. 204). Triple phosphates, fatty-acid crystals, 
and hsematoidin are likewise frequently seen, the presence of the 
latter, of course, indicating a previous admixture of blood. 

Chylous and Chyloid Exudates. 

Chylous and chyloid exudates have been repeatedly observed. 
They are most frequently met with in the abdominal cavity (104 
times out of the total number of 155, which have thus far been re- 
ported), less commonly in the pleural cavity (forty-nine times), and 
only rarely in the pericardial sac (twice only). Quincke believes 
that the two forms can be etiologically distinguished from one an- 
other by means of a microscopic examination, as the cloudy appear- 
ance in the chyloid form is usually referable to the presence of 
endothelial or epithelioid cells undergoing fatty degeneration. Later 
observations, however, have shown that the differentiation of the 
two forms cannot be made upon this basis, as the same anatomical 
lesion, such as carcinoma, may at times give rise to the formation 
of a chylous exudate, at others to that of the chyloid form, and both, 
moreover, may coexist. 

Senator claimed that the presence of more than mere traces of 
sugar is strongly suggestive of the chylous nature of the exudate. 
Possibly this observation may be of some value, but it must not be 
forgotten that sugar is quite commonly met with in all forms of 
transudates and exudates. The presence of more than 0.2 per cent, 
can only be of value. 

Chylous exudates in their general appearance resemble milk, while 
the chyloid fluid is more suggestive of pus. The turbidity in both 
cases is usually referable to the presence of innumerable fat globules, 
which are especially abundant in the chylous form. In chyloid exu- 
dates the origin of the fat from cellular elements is often apparent at 
once, but, as has been said, it is impossible to draw definite etiologic 
conclusions from that difference. Some chyloid exudates contain no 
fat at all, and Lion has shown that the milky-appearance in such cases 
is owing to the presence of a curious albuminous substance, belong- 
ing to the class of nucleo-albumins. 



CHAPTER IX. 
THE EXAMINATION OF CYSTIC CONTEXTS. 

CYSTS OF THE OVARIES AND THEIR APPENDAGES. 

The material obtained from cysts of the ovaries or their appen- 
dages varies greatly in character. On the one hand it may he 
fluid, clear, of low specific gravity, and contain but little albumin, 
while, on the other, it may be dense, viscous, of colloid appearance, 
and a specific gravity varying between 1.018 and 1.024, owing to 
the presence of a large amount of albumin, viz, serum-albumin, 
serum-globulin, and, most important of all, metalbumin or paralbu- 
min. The latter is almost constantly met with in ovarian cysts, and 
its presence is quite characteristic of fluids derived from this source. 

Test foe Metalbumix. — The fluid is mixed with three times 
its volume of alcohol and set aside for twenty-four hours, when it is 
filtered and the precipitate suspended in water. This is again 
filtered and the filtrate tested in the following manner : 1 . A few 
c.c. are boiled, when in the presence of metalbumin the liquid will 
become cloudy, without the formation of a precipitate. 2. With 
acetic acid no precipitate is obtained. 3. Upon the application of 
the acetic acid and potassium ferrocyanide test the liquid becomes 
thick and assumes a yellowish color. 4. When boiled with Millon's 
reagent a few c.c. of the filtrate will yield a bluish-red color, while 
the addition of concentrated sulphuric acid, without boiling, gives rise 
to a violet color. 

The color of cystic fluids may vary from a light straw to a reddish- 
brown, or even a chocolate ; the latter color may be observed when 
hemorrhage has taken place into the cyst. 

Of morphologic elements, ovarian cysts contain red blood-corpus- 
cles, leucocytes, and at times fatty granules in large numbers, crys- 
tals of cholesterin, hsematoidin, and fatty acids. Most important, 
however, from a diagnostic standpoint is the presence of cylindrical 
or prismatic ciliated epithelial cells, derived from the internal lining 
of the cyst, in the presence of which the diagnosis may be definitely 
made (Fig. 127). At times such cells cannot be demonstrated, as 
they may have undergone fatty degeneration ; moreover, if the epi- 
thelium, lining the cyst, is squamous in character, it may be difficult, 
if not impossible, to arrive at a satisfactory conclusion from an ex- 

516 



CYSTS OF THE OVARIES AND THEIR APPENDAGES. 517 



animation of the morphologic elements alone. Colloid concretion,-;, 
which may vary in size from several micromillimetres to 0.1 mm., 
are occasionally observed, and more particularly in colloid cysts. 
They may be recognized by their irregular form, their homogeneous 
appearance, their slightly yellowish color, and delicate outlines. 

In dermoid cysts, epidermal cells and occasionally hairs are 
observed. 

Fig. 127. 




Contents of an ovarian cyst. (Eye-piece III., obj. 8 a, Reichert.; 
a, Squamous epithelial cells ; b, Ciliated epithelial cells ; c, Columnar epithelial ce lis : </, 
Various forms of epithelial cells ; e, Fatty squamous epithelial cells ; /, Colloid bodies ; g, Cho- 
lesterin crystals. 

The differential diagnosis of ovarian, parovarian, and fibre-cystic 
(uterine) cysts cannot always be made from the character of the fluid 
withdrawn by puncture, but at times it is possible. The most im- 
portant points of difference are here given : 1. The fluid in ovarian 
cystomata is usually more or less viscid, and often contains non- 
nucleated granular corpuscles, about the size of leucocytes, the gran- 
ules not dissolving in acetic acid, nor disappearing when treated with 
ether. In all probability they are free nuclei and are often called 
Drysdale's corpuscles in our country. 2. In parovarian cysts the 
fluid is thin, watery, of low specific gravity (under 1.010), and con- 
tains very few morphologic elements. Cylindrical epithelium is 
very rarely found during life in the fluid withdrawn by aspiration 
from cither ovarian or parovarian cysts, o. The fluid from fibro- 
cystic tumors of the uterus is thin, watery, and coagulates spon- 
taneously, while that from ovarian and parovarian cysts never coag- 
ulates spontaneously, unless blood is present. Fibro-cystic turners of 
the uterus have no epithelial lining. 



518 THE EXAMINATION OF CYSTIC CONTENTS. 

HYDATID CYSTS. 

Hydatid cysts are scarcely ever seen in this country. The fluid in 
question is clear, alkaline, of a specific gravity varying between 
1.006 and 1.010, and contains no albumin. Succinic acid is usually 
present, and may be demonstrated by acidifying a small amount of 
the fluid with hydrochloric acid and evaporating to dryness. The 
residue is extracted with ether and the ether evaporated ; the 
aqueous solution of the second residue, in the presence of succinic 
acid, will yield a rust-colored gelatinous precipitate when treated 
with a few drops of a solution of the sesquichloride of iron. Sodium 
chloride is always present in notable amounts, and may be recognized 
by evaporating a drop of the liquid upon a slide, when the charac- 
teristic crystals of salt w r ill be found. Most important, of course, is 
the microscopic examination, which may reveal the presence of hook- 
lets and shreds of membrane, and at times of scolices (see Sputum). 

HYDRONEPHROSIS. 

The diagnosis of hydronephrosis can usually be made without diffi- 
culty, if a sufficient amount of fluid can be obtained, as the presence 
of urea and uric acid in notable quantities, as well as of renal epithelial 
cells, which latter especially should be sought for, is quite character- 
istic. Small amounts of uric acid may also be present in ovarian 
cysts. 

PANCREATIC CYSTS. 

These cysts may be recognized by the fact that the fluid possesses 
the power of digesting albumin in alkaline solutions. A small 
amount of the liquid is added to milk, when after precipitation of 
the casein, the biuret test is applied ; a positive reaction indicates 
the presence of trypsin. Unfortunately, however, this test does not 
always yield positive results, even if the fluid in question is derived 
from a pancreatic cyst, as the trypsin is apparently destroyed in the 
course of time. The larger the size of the cyst, the less likely will 
it be possible to obtain the reaction. A positive result is hence 
only of value, while a negative result does not exclude the existence 
of the disease. 



CHAPTER X. 

THE EXAMINATION OF THE CEREBRO-SPINAL 

FLUID. 

According to our present knowledge, the cerebro-spinal fluid is 
secreted by the choroid plexuses into the lateral ventricles. Passing 
through the foramina of Monroe, the third ventricle, and the aque- 
duct of Sylvius, on the one hand, it reaches the fourth ventricle and 
enters the cistern-like subarachnoid spaces at the base of the brain, 
through the foramen of Magendie and the lateral clefts of the fourth 
ventricle. On the other hand, a certain portion of the fluid reaches 
the same destination directly through the cleft in the descending horn 
of each lateral ventricle. The larger portion of the fluid then passes, 
upward through the subarachnoid spaces along the convexity of the 
brain to the Pacchionian granulations, while the smaller portion en- 
ters the vertebral canal through the subarachnoid spaces of the spinal 
arachnoid membrane. 

Within recent years puncture of the vertebral canal has been 
frequently resorted to, both for therapeutic and diagnostic purposes. 
The practical value of this method of diagnosis is now beyond ques- 
tion, and it is to be hoped that ere long physicians will resort to 
spinal puncture in obscure cases of cerebro-spinal disease, with as 
little hesitancy as puncture of the thoracic and abdominal cavities is 
now practised. 

The operative method to be employed is the following : With the 
patient placed upon his left side, — some observers prefer the sitting- 
posture, — and the body bent well forward, a long aspirating-needle 
is introduced upon a level with the lower third of the third or fourth 
lumbar spinous process, and about one em. to the side of the median 
line, the needle being directed slightly upward and inward. The 
depth to which it is necessary to puncture will, of course, vary with 
the age of the patient. In a child two years of age the vertebral 
canal may be reached at a depth of two centimetres, while in the 
adult it is necessary to insert the needle for a distance o( from 1 to 
8 cm. As soon as the subarachnoid space 1 is reached cerebro-spinal 
fluid will flow from tlu^ needle. Aspiration should always be avoided. 

Some writers have advised that the operation be performed under 
narcosis, and without doubt this may be necessary at times, par- 

5 1 



520 EXAMINATION OF THE CEREBROSPINAL FLUID. 

ticularly when contracture of the dorsal muscles exists. In the 
majority of cases, however, it is not necessary. 

Amount. — So far as I have been able to ascertain, no observations 
have thus far been made regarding the amount of fluid which may 
be obtained by puncture in normal individuals. In all probability, 
however, this is small. Under pathologic conditions the amount may 
vary from a few drops to 100 c.c, and even more. In'general terms 
it may be. stated that the amount is directly proportionate to the de- 
gree of intra-cranial pressure. Exceptions, however, are frequent. 
Small amounts of cerebro-spinal fluid or none at all may thus be 
obtained, when owing to the formation of a thick exudate, or the ex- 
istence of a cerebral tumor the communication between the basilar 
subarachnoid spaces of the brain and those of the spinal cord has been 
interrupted. Whenever, then, symptoms of intra-cranial pressure 
exist, while no fluid or minimal amounts only can be obtained by 
puncture, the conclusion will usually be justifiable that we are deal- 
ing with a purulent meningitis or with a tumor of the brain, and 
more especially of the cerebellum. It should be remembered, how- 
ever, that the same result may be obtained in cases of obliteration of 
the aqueduct of Sylvius, or when sclerotic processes involve the fora- 
men of Magendie, which is occasionally observed in certain forms of 
hydrocephalus. Adhesions of the pia mater to the arachnoid and 
the dura mater may, by interfering with the flow of cerebro-spinal 
fluid, also lead to the formation of hydrocephalus, but in these cases a 
tumor can usually be excluded, as the changes in question always 
develop as sequela? to a meningitis. A serous or tubercular menin- 
gitis, as well as acute hydrocephalus and tetanus, can, however, 
always be excluded when only minimal amounts of fluid are obtained 
by puncture. The largest amounts, on the other hand, are seen in 
cases of serous meningitis, tubercular meningitis, and cerebral tumors, 
which do not interfere with the circulation of the cerebro-spinal fluid. 

Appearance. — formal cerebro-spinal fluid, as well as that obtained 
in cases of serous meningitis, tubercular meningitis, hydrocephalus, and 
tumors of the brain, is perfectly clear, and as a rule colorless, unless 
a small blood-vessel has been punctured, when the fluid may present 
a slightly reddish tinge. More or less pronounced yellow shades 
are, however, also at times observed. Important from the standpoint 
of diagnosis is the fact that in cases of hemorrhage into the ventricles 
pure blood is obtained, while such a result is, of course, a mechanical 
impossibility in cases of epidural hsematorna. In subdural hematoma, 
on the other hand, blood may also find its way into the subarachnoid 
space, but the amount is always small, and cannot be compared with 
that seen in cases of ventricular hemorrhage. Whenever, then, as in 
traumatic cases with severe cerebral symptoms, the surgeon is con- 
fronted with the question whether or not to trephine, puncture of 



EXAMINATION OF THE CEREBROSPINAL FLUID. 521 

the subarachnoid space may furnish much valuable information. If 
in such cases no blood at all is obtained, it may be inferred that an 
epidural hsematoma or a subdural hematoma of slight extent only 
exists ; an operation might then be performed. If, however, pure 
blood is found, it would be justifiable to assume the existence of 
extensive injury to the brain-substance proper, or in cases in which 
the history of the case is obscure, an intra-cerebral hemorrhage with 
rupture into the ventricles. In such cases the idea of an operation 
would, of course, only be* entertained under exceptional conditions. 
If, further, the fluid is only tinged with blood, a subdural hematoma 
probably exists, and an operation could be advised. Accidental 
hemorrhage, viz, hemorrhage referable to the puncture itself, can be 
readily recognized, as the first few drops only are then tinged with 
blood, or the blood appears only after the flow has been definitely 
established ; the amount, moreover, is insignificant. 

Cloudy fluid is obtained in all cases of purulent meningitis unless 
the disease is limited to a very small area. This is, of course, most 
important from a diagnostic standpoint. Cases of abscess of the brain 
or sinus thrombosis occur again and again in which the question as 
to the advisability of operative interference is largely dependent upon 
the presence or absence of a complicating purulent meningitis. In 
certain instances a satisfactory conclusion may, of course, be reached 
without puncture ; but in many others this is impossible, and Licht- 
heim's dictum, that an operation should never be undertaken in such 
cases unless the integrity of the meninges has been established by 
spinal puncture, should be borne in mind. 

The degree of cloudiness naturally varies in different cases, and 
while in some instances the character of the fluid is sero-purulent, 
pure, creamy pus may be found in others. Generally speaking, a 
cloudy fluid indicates the existence of an acute inflammatory process 
or an acute exacerbation of a chronic process. 

Important, furthermore, is the fact that the fluid in non-inflam- 
matory diseases of the brain, such as tumor or abscess, rarely under- 
goes coagulation, while this is the rule in all inflammatory diseases. 
In tubercular meningitis the coagula are very delicate, and may be 
well compared to spider-webs, which extend throughout the fluid, 
while in purulent meningitis the coagula are much firmer. 

Specific Gravity. — The specific gravity of cerebro-spinal fluid 
normally varies between 1.005 and 1.007, corresponding to the 
presence of from 10 to 15 p. m. of solids. Under pathologic condi- 
tions variations from 1.003 to 1.012 may be observed, the specific 
gravity, generally speaking, being higher in the inflammatory than 
in the non-inflammatory diseases of the brain. From a diagnostic 
standpoint, however, the determination of the specific gravity is of 
little value, as numerous exceptions occur to the above rule. 



522 EXAMINATION OF THE CEREBROSPINAL FLUID. 

The reaction is always alkaline. 

Chemical Composition. — An idea of the chemical composition of 
the cerebro-spinal fluid may be formed from the following analysis, 
taken from Gautier : 

Water 987.00 

Albumin 1.10 

Fat 0.09 

Cholesterin . . . 0.21 

Alcoholic and aqueous extract, minus salts \ ^ 75 
Sodium lactate . . . . .J 

Chlorides 6.14 

Earthy phosphates . .... 0.10 

Sulphates 0.20 

Ammonia . . . . . . . . 

In addition, urea is at times found, as also a substance which re- 
duces Fehling's solution and gives rise to a brown color, when boiled 
with caustic potash, but which neither undergoes fermentation nor 
forms an osazon when treated with phenyl hydrazin. The substance 
in question is generally regarded as pyrocatechin. Its amount varies 
between 0.002 and 0.116 per cent. According to C. Bernard glucose 
is also present, but it is questionable whether this is actually the case 
under normal conditions (see below). Nawratzki discovered a re- 
ducing substance in his cases, which was demonstrated to be glucose ; 
his subjects, however, were unfortunately not normal, but general 
paretics with fever. Pyrocatechin was absent. So far as the albu- 
minous bodies are concerned which may be found in the cerebro-spinal 
fluid, serum-albumin is said to be present only under exceptional 
conditions, while normally a mixture of globulin and albumoses is 
found. The question whether or not mucin may also be present is 
still undecided. 

Under pathologic conditions the amount of albumin may vary 
considerably, and is of some diagnostic importance. According to 
the majority of observers the figure given in the above analysis is 
somewhat too high, and it is questionable whether 1 p. m. may be 
regarded as normal. The lowest values have been obtained in cases 
of chronic hydrocephalus (traces only), meningitis serosa (0.5 to 0.75 
p. m.), and tumors of the brain (traces to 0.8 p. m.), while the largest 
amounts have been found in chronic hydrocephalus, the result of 
hyperemia (1 to 7 p. m.), and tubercular meningitis (1 to 3 p. m.). 
Nawratzki in recent examinations found amounts varying between 
0.047 and 0.170 per cent., but the subjects of his investigation had 
fever at the time. 

Lichtheim claims to have found glucose — by means of the phenyl- 
hydrazin test — in all cases of tumor which he examined. In cases 
of tubercular meningitis, on the other hand, a positive result was 
only exceptionally obtained. Quincke also reports that he was able 



EXAMINATION OF THE CEREBROSPINAL FLUID. 523 

to demonstrate the presence of sugar whenever the liquid obtained 
was sufficient in amount for the necessary tests. Unfortunately, 
however, he does not detail his cases. Concetti found no sugar in 
hydrocephalic fluid. 

The experience of other observers does not agree with that of 
Lichtheim and Quincke, and Furbringer, who has thus far reported 
the largest number of spinal punctures, has found sugar in only two 
cases of diabetes associated with tuberculosis. 

Microscopic Examination. — The microscopic examination of the 
fluid, withdrawn by spinal puncture, is most important. 

Under normal conditions, as well as in cases of tubercular menin- 
gitis, tumor, abscess, acute and chronic hydrocephalus, only a few 
leucocytes and endothelial cells from the subarachnoid spaces are 
usually found, enclosed in extremely delicate meshes of fibrin. In 
purulent meningitis, on the other hand, leucocytes are present in 
large numbers, and in some instances pure pus may even be obtained. 

Most important from a diagnostic standpoint is the fact that patho- 
genic micro-organisms may be found. Lichtheim, Furbringer, Frey- 
han, Dennig, and Frankel were thus able to demonstrate the presence 
of tubercle bacilli in a fairly large number of cases of tubercular 
meningitis. Other observers, it is true, have been less fortunate, 
but the fact that Furbringer found tubercle bacilli in thirty cases out 
of thirty-seven is certainly significant. Schwarz states that he ob- 
tained positive results in 16 out of 22 cases, and Slawyk and Manica- 
tide obtained them in all of 19 cases (16 times by direct microscopic 
examination, and 3 times by the animal experiment). In order 
to examine for tubercle bacilli the fluid should be placed on ice 
for from 6-24 hours, until a slight coagulum has formed, when the 
fine spider-web-like threads of fibrin arc transferred to a cover-slip, 
spread out in as thin a layer as possible, and stained, as described in 
the chapter on Sputum. If a centrifugal machine is available, the ex- 
amination may, of course, be made at once, and the chances of find- 
ing the bacilli arc undoubtedly much greater. In every case a large 
number of specimens should be prepared before the search is aban- 
doned. A positive result, however, is only of value, and in doubtful 
cases recourse should be had to the animal experiment. 

In the diagnosis of epidemic cerebro-spinal meningitis lumbar 
puncture is of signal value, as the diplocoGCUS meningitidis intraeellu- 
laris of Weichselbaum-Jager, can be demonstrated in a very largo 
percentage of cases. Councilman thus states that during the recent 
epidemic of the disease in Boston, lumbar puncture was performed 
in fifty-five eases, and that, in the fluid obtained, the diplococci were 
found on microscopic examination or in culture in thirty-eight 
cases. The average duration of time from the onset of tin 1 disease 
before spinal puncture was made, was seven days in the positive 



524 EXAMINATION OF THE CEREBROSPINAL FLUID. 

cases, and seventeen days in the negative cases. The longest time 
after the onset, in which a positive result was obtained was twenty- 
nine days. Similar results have also been reached by other observers. 

The organism in question is a diplococcus, each hemisphere being 
of about the same size as the ordinary pathogenic micrococci. It is 
readily stained with the usual dyes, and decolorized by Gram's 
method. Short chains of from four to six, and tetrads may at 
times be seen. It grows best upon Loffler's blood-serum mixture, 
forming round, whitish, shining, viscid-looking colonies, with 
smooth, sharply denned outlines, which may attain a diameter of 
from 1-1J mm., in twenty-four hours. Their cultivation upon plain 
agar, glycerin-agar and in bouillon is less reliable. 

In order to obtain the best results it is necessary to use large 
amounts of the exudate, and to make a number of cultures, as 
many of the organisms are usually dead, or will at least not grow. 

In ordinary coverslip-preparations they are often quite nu- 
merous, and found enclosed in the polynuclear leucocytes. Their 
number then varies considerably. On the one hand only one or two 
may be present in a cell, while in others they may be so closely 
packed, as to obscure the nucleus. 

Mixed infections are not uncommon in epidemic cerebro-spinal 
meningitis. Councilman thus found the pneumococcus in seven 
cases, and Friedlander's bacillus in one. Terminal infections with 
staphylococci and streptococci also occur. 

In other forms of purulent meningitis a large variety of organ- 
isms has been found. Wolf gives the following figures, resulting 
from an analysis of 174 cases, in which epidemic cerebro-spinal 
meningitis is however included : in 44.23 per cent, the pneumococcus 
was found ; in 34.48 per cent, the diplococcus meningitidis intracel- 
lulars ; in 3.45 per cent, staphylococci ; in 8.03 per cent, strepto- 
cocci, in 1.13 per cent, the bacillus of Friedlander ; in 2.87 per 
cent, the bacillus typhosus ; in 1.72 per cent, the bacillus of Neu- 
mann -SchafPer, and in 2.87 per cent, the bacillus coli communis, the 
bacillus pyogenes foetid us, the bacillus aerogenes meningitidis, and 
the bacillus mallei, while no bacteria were found in 1.15 per cent, of 
the cases. 



CHAPTER XI. 

THE SEMEN. 

DEFINITION. 

The ejaculated semen is a mixture of the secretions furnished by 
the testicles, the prostate gland, the seminal vesicles, and the glands 
of Cowper. 

GENERAL CHARACTERISTICS. 

Semen is white or slightly yellowish in color, semi-fluid, sticky, 
and of an opaque, non-homogeneous, milky appearance, which is due 
to the presence of white, opaque islets floating in the otherwise clear 
fluid ; these consist almost entirely of the specific morphologic ele- 
ments of the semen, the spermatozoa. Its odor, which strongly re- 
sembles that of fresh glue, is very characteristic, and is owing to the 
presence of spermin. It is generally attributed to an admixture of 
prostatic fluid, as the semen obtained from the vasa deferentia is 
odorless. According to Robin, however, this odor is only produced 
at the moment of ejaculation, and cannot be ascribed to any single 
one of the secretions present. The reaction of human semen is 
slightly alkaline, and its specific gravity greater than that of water, 
in which it readily sinks. 

CHEMISTRY OF SEMEN. 

Curiously, no accurate analyses of human semen or of mamma- 
lian semen have been made, and only the old analyses of Vauquelin 
and Kollicker can be given. 





Man. 


Horse. 


Ox. 


Water . 


. 90 


81.9 


82. 1 


Albuminous material ] 




] 16.45 


15.3 


Extractives . j- 


. 6 




Ethereal extract J 




o •> 


Mineral material 


. 4 


I. til 


2.6 



evano- 



The mineral matter consists largely of calcium phosphate. 

If semen is kept for any length of time, or it' it i< slowly evap 
rated, crystals of spermin will separate out. These have been shown to 
bo chemically identical with the phosphate 1 of ethylenimin, C 2 H 4 (N H), 
and hence with the so-called Charcot-Leyden crystals, so frequently 
seen in asthmatic sputa and in the blood of leukemic patients. 

525 



526 



THE SEMEX. 



MICROSCOPIC EXAMINATION OF THE SEMEN. 

Upon microscopic examination normal semen is seen to contain 
innumerable, actively moving, thread-like bodies, measuring from 
50 tt to 60 ti in length, the spermatozoa. These consist, of an egg- 
shaped head, when seen from above, which is from 3 a to 5 it in 
length, the broader end being directed anteriorly ; a middle portion, 
4 tt to 6 it in length, with which the head is united by its smaller 
end ; and a posterior piece or tail, into which the middle piece grad- 
ually fades (Fig. 128). 

Fig. 128. 




Human semen, a, Spermatozoa; b, Cylindrical epithelium; c, Bodies enclosing lecithin gran- 
ules ; d, Squamous epithelium from the urethra ; d', Testicle cells ; e, Amyloid corpuscles ; /, Sper- 
rystals ; g, Hyaline globules, (t. Jaksch.) 



matic crystals ; g, 



In addition to the spermatozoa a few hyaline bodies are seen which 
are derived from the seminal vesicles ; further, numerous small, pale 
granules of an albuminous nature, some testicular and urethral epi- 
thelial cells, lecithin-corpuscles, and so-called prostatic or amyloid 
corpuscles, which at first sight resemble starch-granules in appearance, 
owing to their concentric striations. A few leucocytes and occasion- 
ally a few red corpuscles may also be found. 



PATHOLOGY OF THE SEMEN. 

The study of the semen has as yet received but little attention 
from clinicians, and gynecologists frequently hold the wife respon- 
sible for sterility, where an examination of the husband's semen would 
— according to Kehrer, in 40 per cent. — reveal an absence of sperma- 
tozoa, constituting the condition usually spoken of as azoospermatlsm. 
This may be temporarily observed following venereal excesses, when 
the fluid finally ejaculated is almost entirely of prostatic origin ; it 
then possesses no significance, but persistent azoospermatism must of 
necessity be associated with sterility. 

Cases have been recorded in which, notwithstanding the presence 
of spermatozoa and otherwise normal sexual conditions in both hus- 



THE RECOGNITION OF SEMEN IN STAINS. 527 

band and wife, sterility existed nevertheless, but in which it was 
observed that the spermatozoa lost their motile power almost imme- 
diately after ejaculation, while under normal conditions it is a well- 
known fact that, following intercourse, actively moving spermatozoa 
may be found in the vagina after many hours, days, and even weeks. 

Whenever it is deemed advisable to make an examination of the 
semen, this should be done immediately following ejaculation, or as 
short a time as possible at least be allowed to elapse. ISote should 
then be taken, not only of the presence, but also of the motility of 
the spermatozoa ; a drop of the semen is mixed with a drop of 
normal (0.6-per-cent.) saline solution, and examined at once with the 
microscope. 

Bloody semen constituting the condition, which is spoken of as 
kcemospermia, has been observed on several occasions. It may fol- 
low excessive sexual indulgence, but may also occur in connection 
with gonorrhoeal epididymitis. The blood is readily recognized 
upon microscopic examination. 

THE RECOGNITION OF SEMEN IN STAINS. 

In medico-legal cases the physician may be called upon to decide 
whether or not certain stains on the linen are caused by spermatic 
fluid, whether or not a rape has been committed, etc. In such cases 
it is frequently only necessary to examine a drop of the vaginal fluid 
in order to arrive at a positive result at once. At other times, how- 
ever, recourse must be had to the following method : A fragment of 
the linen or scrapings from the vulva or vagina are placed in a watch- 
crystal and allowed to soak for at least one hour in from 27- to 30- 
per-cent. alcohol, when a bit of the material is teased in a solution of 
eosin in glycerine (1 : 200), and examined. The heads of the sper- 
matozoa are thus stained a deep red, while the tails, which are often 
found broken, exhibit a pale rose-tint, and can readily be distin- 
guished from vegetable fibres, which do not take up the stain at all. 
A positive statement can thus be made in every case, even after 
months and years, as the spermatozoa not only resist the action ot % 
reagents, but also the process of putrefaction ; this is probably owing 
to the greater proportion of mineral matter which enters into their 
composition, and which insures the preservation of their form. In- 
stances have been recorded in which it was possible to demonstrate 
the presence of spermatozoa in stains after eighteen years. 

The semen-test which has been recently described by Florence has 
already attracted much attention, and may be recommended in doubt- 
ful cases. It is based upon the observation that very characteristic 
crystals of iodospernrin are formed, when spermatic fluid is treated 
with a solution of iodopotassic iodide, especially rich in Iodine. The 



528 THE SEMES. 

reagent is composed of 1. 65 grammes of pure iodine and 2.54 grammes 
of potassium iodide, dissolved in 26 grammes of water. When a 
drop of this solution is added to a drop of spermatic fluid or an 
aqueous extract of a seminal stain, dark brown crystals of iodosper- 
min separate out at once and may be readily recognized under the 
microscope. They occur in the form of long rhombic platelets, or 
fine needles, often grouped in rosettes, but also occurring singly or 
as twin crystals. The examination with the microscope should be 
made at once after the addition of the reagent, as the crystals gradu- 
ally disappear on standing. 

As the reaction may also be obtained in cases of azoospermatism, 
and with pure prostatic secretion, while a negative result is obtained 
with the fluid from spermatoceles, it is manifest that the test is not 
applicable for the determination of the presence or absence of sper- 
matozoa per se. This fact, however, would rather make the test 
more valuable than otherwise. 

Posner states that he obtained the same crystals when the test was 
applied to a glycerin extract of ovaries, an observation which cannot 
be surprising, as the ovaries, like the testes and prostatic gland, are 
rich in spermin. Xegative results were reached with putrefying 
semen. 



CHAPTER XII. 
VAGINAL DISCHAKGES. 



GENERAL CHARACTERISTICS. 

The secretion which is normally furnished by the vaginal glands 
is small in amount, and just sufficient to keep the mucous membrane 
moist. It is a clear or somewhat milky-looking, semi-liquid ma- 
terial, in which numerous epithelial lamina?, which have been thrown 
off during the normal process of desquamation, may be found. It 
has been stated that the reaction of the vaginal secretion in virgins is 
invariably acid, while an alkaline reaction is the rule in the deflorees. 
During pregnancy, however, the secretion is probably always acid. 
In 500 cases, which Kronig examined in this direction, an alkaline 
reaction was never observed. 

Microscopically numerous epithelial cells, mucous corpuscles, a few 
large, mononuclear leucocytes, cellular detritus, and bacteria are 
found (Fig. 129). Doderlein has described a non-pathogenic 

Fig. 129. 




Vaginal secretion: a, Mucous corpuscles; b, Vaginal epithelium ; e, Epithelium from vulva. 

bacillus or a group of bacilli, which are characterized by the fad 
that they give rise to marked acid fermentation of sugar, and he re- 
gards these organisms as the only ones which are constantly present 
in the normal vagina. Kronig and Mcnge, however, state that they 
are often absent. They have found, on the other hand, that there 
are various bacilli and cocci present under normal conditions, which 
34 529 



530 VAGINAL DISCHARGES. 

belong to the class of obligatory anaerobes and are likewise non- 
pathogenic. Unfortunately they have not described these organisms 
in detail. Near the outlet they found bacteria which can be culti- 
vated upon alkaline aerobic culture media, but which are usually 
absent in the upper portion of the vagina. 

It is important to note that various diplococci may also be found 
under normal conditions, and care should be taken not to confound 
these with gonococci. Like the gonococci they are decolorized by 
Gram's method. If the various characteristics of the former be 
borne in mind, however, mistakes can always be avoided. In mar- 
ried females, and in children especially, it will probably always be 
best to make the diagnosis of gonorrhoea only when the gonococcus 
has been isolated by cultivation. 

The question, whether or not pathogenic bacteria may occur in the 
normal vagina of pregnant or non-pregnant women, may be answered 
in the affirmative, although it must be admitted that with the excep- 
tion of the gonococcus they are only exceptionally found. The vagi- 
nal secretion has been shown to possess most powerful bactericidal 
properties, so that pathogenic organisms, even if they are artificially 
introduced into the vagina, are rapidly killed. Kronig thus found 
that after their artificial introduction the bacillus pyocyaneus disap- 
pears from the vagina of pregnant women in from ten to thirty 
hours, the staphylococci in from six to thirty-six hours, and the 
streptococcus pyogenes within six hours. Important from a prac- 
tical standpoint is the fact that the bacteria disappeared less rapidly 
when irrigation of the vagina with w T ater or even antiseptics was, 
employed. 

Of animal parasites the trichomonas vaginalis is apparently the 
only one which may be encountered in the vaginal discharge. The 
organism is identical with the trichomonas found in the feces and 
the urine. In this country it is rarely observed, while it is decidedly 
common among the peasant population of Central Europe. As far 
as is known the organism is of no pathologic significance, and may 
occur both under normal and pathologic conditions. From a medico- 
legal standpoint, however, its presence may not be unimportant, as 
cases are on record in which trichomonades have been confounded 
with spermatozoa. Such a mistake, in my judgment, can only occur, 
however, if the observer is entirely without microscopic training. 
In doubtful cases the test of Florence may be advantageously em- 
ployed (see p. 527). 

VAGINAL BLENNORRHEA. 

In physiologic conditions an increased vaginal secretion is observed 
during sexual excitement, especially during coitus, just preceding and 
at the beginning of the process of menstruation and during preg- 



THE LOCHIA. 531 

nancy, when a profuse blennorrhcea is frequently seen, which often 
assumes a virulent character. The secretion under such conditions 
readily becomes purulent. When not dependent upon a gonorrhoeal 
infection the secretion is thicker than normal, white and creamy. At 
times also the vaginal catarrh observed in pregnancy is complicated 
with mycosis, when white or yellowish-gray patches may be seen at 
the orifice of the vagina ; the latter may, indeed, even be filled with 
particles which consist entirely of fungi. 

MENSTRUATION. 

At the beginning of menstruation, as has been pointed out above, 
an increase in the amount of vaginal secretion is observed, in which 
leucocytes, prismatic epithelial cells coming from the uterus, as well 
as the usual vaginal cells, may be seen upon microscopic examination. 
Later the secretion becomes sanguineous in character, and finally only 
epithelial cells, leucocytes, and granular detritus are encountered, the 
cells usually showing evidence of fatty degeneration. The amount 
of blood lost at each menstrual period amounts to about 200 grammes, 
in perfectly healthy females. 

THE LOCHIA. 

The lochia during the first day following parturition are red in 
color, the lochia rubra, and emit the characteristic sanguineous odor. 
At this time a microscopic examination will reveal an abundance of 
red corpuscles, some leucocytes, and a variable number of epithelial 
cells, which are almost exclusively of vaginal origin. On the second 
and third days the number of red corpuscles diminishes while the 
leucocytes increase in number. Still later the diminution in the red 
and the increase in the white corpuscles becomes more marked, ami 
the discharge at the same time assumes a grayish or white color, until 
about the tenth day the red corpuscles have almost entirely disap- 
peared, while the leucocytes and epithelial cells are quite abundant. 
Finally, the secretion becomes thicker, mucoid, and milky-white in 
color — the lochia alba, which condition may persist lor from three to 
four weeks in nursing-women, and still longer in those who do not 
nurse, until at last the normal secretion is again established. Numer- 
ous bacteria are encountered in the lochia, and it is curious to note that 
among these pus-organisms are quite constantly present, without 
giving rise to any symptoms. When a portion of the placenta or 
membranes have been retained the lochia soon give off a fetid odor, 
and assume a dirty brownish color ; the retention of blood clot- alone 
may also produce this result. In such eases the lochia swarm with 
bacteria of all kinds. 



532 



VAGIXAL DISCHARGES. 



VULVITIS AND VAGINITIS. 

In cases of vulvitis and vaginitis a marked increase is observed 
in the number of the leucocytes and epithelial cells, the character of 
the latter depending, of course, essentially upon the portion of the 
genital tract affected. Red corpuscles are also met with at times ; 
their number generally stands in a direct relation to the intensity of 
the inflammatory process. In some instances epithelial casts of 
the entire vagina have been observed, constituting the condition 
which has been termed vaginitis exfoliativa. The disease, however, 
is very rare. 

The discharge of large amounts of pure pus through the~vagina 
points to perforation of an abscess of the genital organs or of the 
neighboring structures into the uterus or the vagina, but is of rare 
occurrence. Much more common is the discharge of fecal matter or 
of urine through this channel, indicating the existence of a vagino- 
rectal or vagino- vesical fistula. 

Fig. 130. 




Vaginal secretion from a case of epithelioma of the cervix uteri. 



MEMBRANOUS DYSMENORRHEA. 

While ordinarily, during menstruation, shreds of desquamated 
uterine lining are frequently encountered, it is rare to meet^with 
large pieces or complete casts of the uterus, the elimination of which 
is usually associated with the symptoms of a severe dysmenorrhea, 
constituting the condition generally spoken of as membranous dys- 
menorrhosa. 



MEMBRANOUS DYSMENORRHEA. 



533 



Fio. 131. 




Chorion villi. 



Fig. 132. 




Decidual cells 



534 VAGINAL DISCHARGES. 

CANCER. 

While the diagnosis of malignant growth of the uterus is probably 
never based upon a microscopic examination of the vaginal discharge 
only, it may be mentioned that in advanced cases this is possible, as 
fragments of an epithelioma of the cervix, for example, may fre- 
quently be detected upon microscopic examination (Fig. 130). In 
suspected cases small pieces of tissue should be removed and ex- 
amined according to the usual histologic methods. 

GONORRHEA. 

In suspected cases of gonorrhoea an examination of the vaginal 
and urethral discharge for the presence of gonococci, is most impor- 
tant as it is practically impossible to diagnose this condition posi- 
tively in any other manner. Care should be taken, however, not to 
confound the diplococci, which may be normally present in the urethra 
and vagina, with gonococci (see chapter on Urine). 

ABORTION. 

In cases of abortion it is often possible to discover chorion villi in 
the expelled blood-clots which present the characteristic capillary net- 
work (Fig. 131), and often manifest signs of advanced fatty degener- 
ation. Important also from a diagnostic point of view is the pres- 
ence of decidual cells (Fig. 132), which are characterized by their 
large size, their round, polygonal, or spindle-like form, and their 
characteristic nuclei and nucleoli. 



CHAPTER XIII 



THE SECRETION OF THE MAMMARY GLANDS. 



THE SECRETION OF MILK IN THE NEWLY BORN. 

A secretion from the mammary glands of the male is only ob- 
served in the newly born, if we except those very rare cases where 
adult males were known to suckle infants. The fluid in question, 
which may also be obtained from the female infant, is termed 
" Hexenmilch " (witches' milk) by the Germans. Qualitatively it 
has the same composition as milk, but may manifest considerable 
quantitative variations. 

COLOSTRUM. 

Aside from those curious instances in which a secretion of milk 
has been observed in non-pregnant women, mammary activity is es- 
sentially connected with the physiologic phenomena of pregnancy 
and parturition. Often as early as the third month a small drop of 
a serous-looking fluid can be obtained from the nipple by pressure 
upon the breasts. Immediately after birth a variable amount of fluid 
is secreted, which is watery, semi-opaque, mucilaginous, and of a 
yellowish color. To this secretion, as well as to that observed dur- 
ing pregnancy, the term colostrum has been applied. It is distin- 
guished from true milk by its physical characteristics, and by the 
presence of a greater proportion of sugar and salts. The fluid, more- 
over, is coagulated upon boiling. An idea may be formed of its 
chemical composition from the appended tables : 





4 weeks before birth. 


17 days be- 
fore birth. 


>.> days be- 
fore birth. 


ill hours 
after birth. 


2 days 
after birth. 






Water 


945.2 852.0 


851.7 


858.8 


848.0 


867.9 


Solids 


54.8 148.0 


1 IS.:; 


ill. 'J 


157.0 


132.1 


Casein 














21.8 


Albumin . 


28.8 69.0 


74.8 


80.7 






Fat .... 


7.;; ii.:; 


80.2 


23.5 





48.6 


Lactose . 


17.3 89.5 




36. l 





01.0 


Salts .... 


i.t i.t 


1.5 


V t 


5.1 





Upon microscopic examination minute fat-droplets, ;i tow leuco- 
cytes, some epithelial colls, ami so-called wlostrurn-corpusclcs arc 



536 



THE SECRET] ON OF THE MAMMARY GLANDS. 



found. The latter are highly refractive bodies of irregular size, 
whose interior is filled with fatty granules (Fig. 133). 

THE SECRETION OF MILK PROPER, IN THE ADULT 

FEMALE. 

The secretion of rnilk proper usually begins about the third day 
following parturition, and may continue for a variable length of time. 
On the one hand, the amount of milk secreted may be so small as to 
be insufficient for the wants of the child, so that lactation may have 
to cease after several days. On the other hand, women are not in- 

Fig. 133. 







Colostrum of a woman in sixth month of pregnancy. (Eye-piece III., obj. 

(v. Jaksch.) 



a, Reichert. ) 



frequently seen who nurse their children for two years and even 
longer. Usually, however, infants are nursed until six or seven 
teeth have appeared, which period varies with the individual child, 
averaging about the eleventh month. 

HUMAN MILK. 

Human milk is of a bluish color, and differs in this respect from 
the milk of cows. Its reaction is alkaline. The specific gravity 
may vary between 1.026 and 1.035, one between 1.028 and 1.034 
being the most common. The amount of milk secreted in twenty- 
four hours varies from 500 to 1,500 c.c. Microscopically it is a 
fairly homogeneous emulsion of fat, and practically destitute of cel- 
lular elements. From the following table an idea may be formed of 
its chemical composition : 





Biehl. 


Gerber. 


Christenn. 


Pfeiffer. 


Pfeiffer. 


Mendes de 
Leon. 


Water .... 


876.0 - 


891.0 


872.4 


892.0 


890.6 


877.9 


Solids .... 


124.0 


109.0 


127.6 


108.0 


109.4 




Albumin . 


22.10 


17.90 


19.00 


16.13 


17.24 


25.30 


Fat ... . 


38.10 


33.00 


43.20 


32.28 


29.15 


38.90 


Lactose 


60.90 


53.90 


59.80 


57.94 


59.92 


55.40 


Salts .... 


2.90 


4.20 


2.60 


1.65 


2.09 


2.50 



THE MILK IN DISEASE. 5-37 

Upon comparing this table with the following analysis of cow's 
milk, it will be seen that the latter contains more albumin and less 
sugar than human milk. Human milk, moreover, is relatively de- 
ficient in mineral matter and especially in calcium salts and phosphoric 
acid : 

Water 874.2 

Solids 125.8 

Casein 28.8 \ . - 

Albumin 5.3/ * L0 

Fat 36.6 

Lactose . . . . . . . .48.1 

Salts 7.1 

The albumins found in milk-plasma are casein, lacto-globulin, and 
lactalbumin. It is claimed by numerous observers that the casein 
of human milk differs from that obtained from cow's milk. The 
casein-coagula in human milk are not so large and dense as those 
observed in cow's milk. Human casein, moreover, is not so readily 
precipitated by acids and salts ; it does not always coagulate upon 
the addition of rennet ferment, and while it can be precipitated by 
the gastric juice it is readily dissolved by an excess. Although ac- 
curate analyses of human casein are not available, it is probable that 
the two forms are not identical (Hammarsten). 

The question whether or not normal human milk contains micro- 
organisms may now be answered in the affirmative. There can be 
no doubt, however, that the milk, as it is secreted by the healthy 
gland, is sterile, but upon passing along the lacteal ducts in the nipple 
it is always contaminated by the staphylococcus epidermidis albus 
(Welch). This micro-organism must be regarded as a constant in- 
habitant of the skin, and is the only one of the cutaneous bacteria 
which regularly penetrates into the deeper layers of the epidermis 
and into the glandular appendages of the skin. It is thus at once 
apparent why this organism is so constantly met with, and practically 
the only one that is found in normal human milk. Exceptionally 
only the staphylococcus pyogenes aureus is found. 

THE MILK IN DISEASE. 

The chemistry of the milk in pathologic conditions has received 
but little attention. It appears, however, that the milk of women, 
while ill, usually contains less fat, and that the proportion of Lactose 
is diminished. In cases of jaundice the presence of bile-pigment 
and of biliary acids has not as yet been satisfactorily demonstrated. 
In cases of mammary tumors bloody secretion has boon observed in 
rare cases, the nipple itself bring intact. 

Microscopically an admixture of leucocytes is observed in various 
diseases of the breast, and especially in cases ofabscess. Of patho- 



538 



THE SECRETION OF THE MAMMARY GLANDS. 



Fig. 134. 



genie micro-organisms streptococci may be found in cases of puer- 
peral fever ; more commonly, however, they are absent. The 
typhoid bacillus has been occasionally seen in 
cases of typhoid fever, and it is interesting to 
note that the specific agglutinins of typhoid fever 
have been noted in the milk. Pneumococci have 
been obtained from the milk of pregnant women 
affected with lobar pneumonia. The important 
question whether or not tubercle bacilli are elimi- 
nated through the milk in cases of phthisis can- 
not be definitely answered. In cows such an 
occurrence is certainly quite common, even when 
there is no demonstrable tuberculosis of the udder. 
So far as I have been able to ascertain they have 
never been found in human milk. 

A blue and red color has at times been observed 
in the milk of cows, owing to the presence of the 
bacillus pyocyaneus and the micrococcus prodi- 
giosus, respectively. 

A chemical examination of the mother's milk 
is often of the greatest importance, and should 
always be made whenever it is apparent that the 
nutrition of the baby is below normal. Most 
valuable dietetic suggestions may thus be ob- 
tained. In other cases, as when the mother is 
unwilling or unable to nurse her child beyond a 
certain period, a knowledge of the composition of 
her milk will enable the physician to give specific 
instructions regarding the proper modification of 
cow's milk. If a wet-nurse is to be employed, 
her milk should likewise be examined. 

Most important is the determination of the 
specific gravity and of the amount of fat. The 
former may vary between 1.029 and 1.033. The 
amount of fat should not be less than 3 per cent. 

Determination of the Specific Gravity. 

The specific gravity is best determined with 
the lactodensimeter of Quevenne (Fig. 134). As 
the instrument is graduated for a temperature of 
60° F., it is necessary to correct the specific grav- 
ity, whenever the temperature rises above or falls 
below this point. In the following tables the corrected specific gravity 
may be found corresponding to temperatures ranging from 46° to 
75° F. : 




Quevenne's lactoden- 
simeter. 



THE MILK IN DISEASE. 



539 



Corrections for Temperature. 



Specific 






Degrees of thermometer (Fahrenheit). 






gravity. 


46 


47 


48 


49 


50 


51 


52 


53 


54 


| 66 


1020 


19.0 


19.1 


19.1 


19.2 


19.2 


19.3 


19.4 


19.4 


19.5 


19.6 


1021 


20.0 


20.0 


20.1 


20.2 


20.2 


20.3 


20.3 


20.4 


20.5 


20.6 


1022 


21.0 


21.0 


21.1 


21.2 


21.2 


21.3 


21.3 


21.4 


21.5 


21.6 


1023 


22.0 


22.0 


22.1 


22.2 


22.2 


22.3 


22.3 


22.4 


22.5 


22.6 


1024 


22.9 


23.0 


23.1 


23.2 


23.2 


23.3 


23.3 


23.4 


23.5 


23.6 


1025 


23.9 


24.0 


24.0 


24.1 


24.1 


24.2 


24.3 


24.4 


24.5 


24.6 


1026 


24.9 


24.9 


25.0 


25.1 


25.1 


25.2 


25.2 


25.3 


25.4 


25.5 


1027 


25.9 


25.9 


26.0 


26.1 


26.1 


26.2 


26.2 


26.3 


26.4 


26.5 


1028 


26.8 


26.8 


26.9 


27.0 


27.0 


27.1 


27.2 


27.3 


27.4 


27.5 


1029 


27.8 


27.8 


27.9 


28.0 


28.0 


28.1 


28.2 


28.3 


28.4 


28.5 


1030 


28.7 


28.7 


28.8 


28.9 


29.0 


29.1 


29.1 


29.2 


29.4 


29.4 


1031 


29.6 


29.6 


29.7 


29.8 


29.9 


30.0 


30.1 


30.2 


30.3 


30.4 


1032 


30.5 


30.5 


30.6 


30.7 


30.9 


31.0 


31.1 


31.2 


31.3 


31.4 


1033 


31.4 


31.4 


31.5 


31.6 


31.8 


31.9 


32.0 


32.1 


32.3 


32.4 


1034 


32.3 


32.3 


32.4 


32.5 


32.7 


32.9 


33.0 


33.1 


33.2 


33.3 


1035 


33.1 


33.2 


33.4 


33.5 


33.6 


33.8 


33.9 


34.0 


34.2 


34.3 



Specific 






Degrees of thermometer (Fahrenheit). 






gravity. 


56 


57 


58 


'59 


60 


61 


62 


63 


64 


65 


1020 


19.7 


19.8 


19.9 


19.9 


20.0 


20.1 


20.2 


20.2 


20.3 


20.4 


1021 


20.7 


20.8 


20.9 


20.9 


21.0 


21.1 


21.2 


21.3 


21.4 


21.5 


1022 


21.7 


21.8 


21.9 


21.9 


22.0 


22.1 


22.2 


22.3 


22.4 


22.5 


1023 


22.7 


22.8 


22.8 


22.9 


23.0 


23.1 


23.2 


23.3 


23.4 


23.5 


1024 


23.6 


23.7 


23.8 


23.9 


24.0 


24.1 


24.2 


24.3 


24.4 


24.5 


1025 


24.6 


24.7 


24.8 


24.9 


25.0 


25.1 


25.2 


25.3 


25.4 


25.5 


1026 


25.6 


25.7 


25.8 


25.9 


26.0 


26.1 


26.2 


26.3 


26.5 


26.6 


1027 


26.6 


26.7 


26.8 


26.9 


27.0 


27.1 


27.3 


27.4 


27.5 


27.6 


1028 


27.6 


27.7 


27.8 


27.9 


28.0 


28.1 


28.3 


28.4 


28.5 


28.6 


1029 


28.6 


28.7 


28.8 


28.9 


29.0 


29.1 


29.3 


29.4 


29.5 


29.6 


1030 


29.6 


29.7 


29.8 


29.9 


30.0 


30.1 


30.3 


30.4 


30.5 


30.7 


1031 


30.5 


30.6 


30.8 


30.9 


31.0 


31.2 


31.3 


31.4 


31.5 


31.7 


1032 


31.5 


31.6 


31.7 


31.9 


32.0 


32.2 


32.3 


32.5 


32.6 


32.7 


1033 


32.5 


32.6 


32.7 


32.9 


33.0 


33.2 


33.3 


33.5 


33.6 


33.8 


1034 


33.5 


33.6 


33.7 


33.9 


34.0 


34.2 j 


34.3 


34.5 


34.6 


34.8 


1035 


34.5 


34.6 


34.7 


34.9 


35.0 


35.2 1 


35.3 


35.5 


35.6 


35.8 



Specific 


Degrees of thermometer (Fahrenheit). 


gravity. 


66 


67 


68 


69 


70 


71 


72 


73 


74 


75 


1020 


20.5 


20.6 


20.7 


20.0 


21.0 


21.1 


21.2 


21.3 


2l.:> 


21.6 


1021 


21.6 


21.7 


21.8 


22.0 


22.1 


22 •> 


22.:; 


22. l 


22.5 


22.6 


1022 


22.6 


22.7 


22.8 


23.0 


23.1 


23.2 


2::.:', 


23.4 


2:;.:. 


2:5. 7 


1023 


2:5.6 


23.7 


23.8 


21.0 


24.1 


24.2 


21.:; 


21.4 


24.6 


21.7 


1021 


24.6 


24.7 


24.9 


25.0 


25.1 


25.2 


2:..:; 


25.5 


25.6 


2.".. 7 


1025 


25.6 


25.7 


25.9 


26.0 


26.1 


26.2 


26. 1 


26.5 


26.6 


26.8 


1026 


26.7 


26.8 


27.0 


27.1 


27.2 


27.3 


27.1 


27..". 


27. 7 




1027 


27.7 


27.S 


2S.0 


28.1 


28. 2 


28.8 


28. 1 


2S.6 


28.7 


28.9 


1028 


2S.7 


2S.S 


29.0 


29.] 


29.2 


29. 1 


29.5 


29.7 


29.S 


29.9 


102'.) 


29.8 


29.9 


30.1 


30.2 


30.3 


80. 1 


80.5 


30.7 


80.9 


31.0 


1030 


30.8 


30.9 


31.1 


31.2 


31.3 


81.5 


31.6 


31.8 


31.9 


32.1 


1031 


31.8 


32.0 


32.2 


32.2 


32. 1 


32.5 


82.6 


32.8 


83 u 




1032 


32.9 


3:5.0 


33.2 


33.3 


33. 1 


38.6 


83.7 


88.9 


84.0 


31.2 


1033 


33.9 


34.0 


34.2 


34.3 


84.5 


34.6 


84.7 


84.9 


85. 1 


8 


L034 


34.9 


35.0 


35.2 


85.8 


:;:>.:> 


85.6 


85.8 


:\<\.o 


36.1 


86.3 


1035 


85.9 


36.] 


86.2 


86. 1 


36.:. 


86.7 


36. S 


87 


37.2 





540 



THE SECRETION OF THE MAMMARY GLANDS. 



The Estimation of Fat. 

The estimation of the fat is most conveniently made by means of 
the lactoscope of Feser, shown in Fig. 135. Milk is drawn into 

Fig. 135. 




Feser's lactoscope. 

the pipette up to the mark M, when it is emptied into the cylinder 
G. The pipette is then rinsed with water and the washings are added 
to the milk. While shaking, water is added, until the black lines 
upon the milk-colored glass plug A can just be discerned. The fig- 
ure upon the right of the scale which is reached by the mixture will 
at once indicate the percentage-amount of fat, while the number upon 
the left indicates the amount of water in c.c. that has been added. 



Estimation of the Proteids. 

Woodward's Method. — Two " milk-burettes " (see Fig. 136), 
each containing 5 c.c. of milk, are kept at a temperature of from 37°- 
40° C, for from 18-24 hours. At the end of this time the milk 



THE MILK IN DISEASE. 541 

has separated into two layers, viz, an upper layer of viscid, yellow 
fat, and a lower layer of fluid milk, which is quite opaque above, 
and almost translucent below. Clinging to the sides of the tube and 
especially at the bottom, a granular precipitate will be seen. The 
burettes are then cooled, when the milk-serum is withdrawn into two 

Fig. 136. 



Milk burette. 



tubes graduated to 15 c.c, and treated with Esbach's reagent to the 
15 c.c. mark. The mixture in each tube is thoroughly stirred with 
a glass rod and then centrifugated to a constant reading. 

Woodward has checked his analysis by Kjeldahl's method and has 
obtained quite satisfactory results. 



INDEX. 



A BOKTION, vaginal discharge in, 534 
J\ Abscess of the liver with perforation 
into the lung, 272 
pulmonary, 272 
Absorption, rate of, in the stomach, 189 
Acetic acid, 176, 203 

fermentation, 176 
tests for, 177, 203 
Acetonemia, 54 
Acetone in the blood, 54 

in the gastric contents, 180 
urine, 448 

quantitative estimation of, 450 

tests for, 449 
Acetonuria, 54, 448 

Acetylene-poisoning, blood changes in, 40 
Acholic stools, 208 
Achroodextrin, 123, 165 
Acid, acetic, 176, 203 

benzoic, 363 

butyric, 176, 204 

capric, 203 

caproic, 203 

carbolic, 201, 440, 446 

diacetic, 452 

diazo-benzene-sulphonic, 443 

formic, 203 

glycuronic, 424 

hippuric, 361 

homogentisinic, 441 

hydrochloric, 139 

isobutyric, 203 

lactic, 168, 453 

oleic, 203 

oxalic, 369 

oxaluric, 369 

oxy butyric, 453 

paimitic, 203 

phosphoric, 304 

picric, 395 

propionic, 204 

stearic, 203 

succinic, 518 

sulphuric, 303 

tauro-cabaininic, 319 

uric, 345 

uroleucinic, 441 

valerianic, 203 
Acids, organic, in the gastric contents, 177 
Actinomyces hominis, 268 
Actinomycosis, 128, 268, 504 
Aden in in the urine, 346, 359 



Agglutinins, 104 
G-granulations of Ehrlich, 68 
Albumin, aceto-soluble, 383, 394 
in the feces, 241 

gastric contents, 162 
urine, 372 
quantitative estimation of, 395 
special tests for serum-albumin, 394 

for serum-globulin, 397 
tests for, 388 

boiling, 391 
nitric acid, 388 
picric acid, 394 
potassium ferrocyanide, 392 
Spiegler's, 394 
trichloracetic acid, 393 
Albuminimeter, Esbach's, 395 
Albuminuria, 372 
accidental, 382 
colliquative, 378 
cyclic, 373 
Da Costa's, 373 
digestive, 381 
febrile, 376 
functional, 373, 380 
hematogenous, 375, 380 
in organic diseases of the kidneys, 375 
intermittent, 373 
mixed, 382, 384 
neurotic, 381 
physiologic, 372 
postural, 373 

referable to circulatory disturbances, 
379 
to impeded outfloAy of urine, 379 
renal, 375, 382 
toxic, 380 
transitory, 378 
Albumoses in the blood, 46 

in the gastric contents, 163 

urine, 383 
tests for, 166, 398 
Albumosuria, 383 
Alkaline stools, L99, 208 

urine, 289 
Alkalinity of the blood, 21 
distribution o\\ W 
estimation of, 28 
Alkapton in the urine. -1-11 
Alkaptonuria, 141 
Alloxur bases in the urine, 346 
estimation o(, 360 
43 



544 



INDEX. 



Almen's solution, 400, 410 
Alveolar epithelium, 259 
Amido acids, 322 
Ammonia in the blood, 50 

gastric contents, 1 79 
Ammoniacal fermentation, 290 
Ammonisemia, 50 
Ammonio-magnesium phosphate, 290, 

467, 477 
Ammonium urate, 476 
Amoeba coli, 217, 261 
Amoebae in the urine, 505 
Amoebic colitis, 244 
Amoebinae in feces, 217 
Amorphous haematoidin, 42, 269, 475 
Amphistomum hominis, 221 
Amphopeptone, 163 
Amphoteric urine, 289 
Amyloid corpuscles in the semen, 526 
Anachlorhydria, 147 
Anacidity, hysterical, 147 
Ana?mia, albuminuria in, 375, 380 
Ana?mic degeneration, 59 
Ankylostomiasis, 216, 232 
Anchylostomum duodenale, 232 
Anguillula intestinalis, 234 

stercoralis, 234 
Anguilluliasis, 216, 234 
Anilin dyes, classification of, 65 

water, gentian-violet, 130 
Animal gum in the urine, 424 

parasites in the blood, 100 
in the feces, 216 
sputum, 261 
urine, 505 
Annelides, 231 
Anthomyia, 217 
Anthracosis of the lung, 275 
Anthrax, bacillus of, 1 07 
Arginin, 163, 321 
Arnold's test, for acetone, 452 
Aronsohn-Philips' stain, 89 
Ascarides in the feces, 231 

in the urine, 505 
Ascaris lumbricoides, 231 

maritima, 232 

mystax, 231 
Asiatic cholera, bacillus of, 235 

feces in, 245 
Asthma, bronchial, Charcot-Leyden crys- 
tals in, 272 
Azoospermatism, 526 

BACILLI of Booker, 239 
Bacillus butyricus, 198 
coli communis, 239 
lactis aerogenes, 239 
of anthrax, 107 

cholera Asiatica, 235 
diphtheria, 129 
Finkler and Prior, 236 
glanders, 108 



Bacillus of influenza, 108, 267 
leprosy, 264 
Le Sage, 239 
Oppler and Boas, 1 85 
smegma, 264 

tuberculosis, methods of stain- 
ing, 265 
in the blood, 107 
feces, 239 

meningeal fluid, 523 
milk, 538 
mouth, 128 
nasal discharge, 247 
sputum, 262 
urine, 502 
typhoid fever, in the blood, 100 
feces, 237 
urine, 501 
yellow fever, 110 
whooping-cough, 267 
pyocyaneus, 240 
Bacteria in the blood, 100 
exudates, 514 
feces, 197, 235 
gastric contents, 185 
milk, 538 
mouth, 124 
nasal seci 
pus, 514 
sputum, 262 
urine, 500 
vagina, 529 
Bacterial decomposition of the urine, 

290 _ 
Bacteriuria, 500 

idiopathic, 504 
Bacterium lactis aerogenes, 239 
Balantidium coli, 223 
Bang' s test for albumoses, 399 

urobilin, 400 
Barfoed's reagent, 168 
Basic anilin dyes, 65 
double stain, 88 

phosphate of magnesium, 468, 476 
Basophilic leucocytes in the blood, 69 

in the sputum, 258 
Baumann and v. Udranszky's method of 

isolating diamins, 459 
Benzoic acid in the urine, 363 
Benzopurpurin-test for hydrochloric acid, 

150 
Bile-pigment in the blood, 53 
in the feces, 241 

gastric contents, 183 
urine, 435 
tests for, 437 

Gmelin's, 437 
Huppert's, 437 
Rosen bach's, 437 
m Smith's, 437 
Bilharzia ha?matobia, 121 
Biliary acids in the blood, 53 



INDEX. 



545 



Biliary acids in the feces, 205 

in the urine, 437 

tests for, 206 
concretions, 212 

analysis of, 213 
Bilirubin, 53, 435, 475 
Biuret test, 330 
Blood, 17 

acetone in, 54 
albumins in, 25, 45 
alkalinity of, 21 
ammonia in, 50 
bacteriology of, 100 
biliary constituents in, 53 
carbohydrates in, 46 
cellulose in, 49 
chemical examination of, 24 
coagulation of, 25 
color of, 17 
color-index, 33 
-corpuscles, red, 17, 55 

degeneration of, 59, 61 

drying and staining of, 83 

enumeration of, 92 
-crisis, 62 
fat in, 27, 52 
fatty acids in, 52 
fibrin in, 25, 45 
gases in, 27 
general characteristics of, 17 

chemistry of, 25 
glycogen in, 48 
hsemokonia of, 92 
in the feces, 208, 215 

gastric contents, 183 

sputum, 251, 258 

urine, 386, 485 
-iron, 34 
lactic acid in, 53 
leucocytes of, 63 
medico-legal test for, 41 
microscopic examination of, 55 
nucleated corpuscles in, 61 
odor of, 18 
parasites in, 100 
parasitology of, 100 
peptone in, 46 
pigments of, 28 
-plasma, 17, 24 
-plates, 91 
proteids in, 45 
protozoa in, 1 10 
reaction of, 20 
-serum, 24, 26 
-shadows, 486 
solids of, 20 
specific gravity of, 18 
sugar in, 27 
tests for, 41, 183 

guaiaeum, 401 

Heller's, 401 

Korczynski and Jaworski's, 
35 



1*09 



Blood, Muller and Weber's, 183 

urea in, 49 

uric acid in, 50 

variations in form of corpuscles, 61 
in number of, 56 
in size of, 55 

white (see Leucocytes), 63 

xanthin bases in, 52 
Boas' bulbed stomach tube, 135 

method for estimating lactic acid 173 

test for lactic acid, 172 
Boas-Oppler bacillus, 185 
Bodo urinarius, 505 
Bothriocephalus latus, 227 
Bottger's test for sugar, 410 
Bremer' s diabetic blood-test, 59 

diabetic-urine test, 421 
Bronchial asthma, 255, 272 
Bronchitis, acute, 271 

chronic, 271 

fibrinous, 272 

putrid, 272 
Browning's spectroscope, 44 
Buccal secretion (see Saliva), 122 
Butyric acid, fermentation, 176 

in the feces, 204 

gastric contents, 176 

test for, 176 

pADAVERIN, 242, 320, 457 
\j Cahn-Mehring' s method of estimat- 
ing fatty acids, 177 
Calcium carbonate, crystals of, 477 

oxalate, crystals of, 467 

phosphate, crystals of, 468 

sulphate, crystals of, 469 
Calliphora erythrocephala, 217 
Calomel stools, 193 
Carbohydrates, digestion of, 164 

in the blood, 46 
feces, 241 
urine, 402 

tests for, 402 
Carbol-fuchsin, 266 
Carbolic acid, estimation of, 447 

tests for, 202, 447 
Carbolo-chloride of iron test, for lactic 

acid, 170 
Carbon monoxide haemoglobin, 39 
Caries of the teeth, 122 
Casein, digestion of, 164 

in the milk, 536 

test for, Leiner's, 214 
Casts, classification of, 4S9 

examination of, 489 

fatty, 492 

fibrinous, 254 

formation of, 494 

granular, 190 

hyaline, 489 

pus, 190 

significance oi\ -196 - 



546 



INDEX. 



Casts, staining of, 489 
urinary, 489 
waxy, 492 
Catarrh, acute intestinal, 242 
bronchial, 271 
chronic intestinal, 243 
duodenal, 243 
intestinal of infants, 244 
of ileum, 243 

jejunum, 243 
large intestine, 211 
Cause's method of estimating sugar, 416 
Cellulose in the blood, 49 
Cenomonadina, 219 
Cercomonas intestinalis, 220, 221 
Cerebro-spinal fluid, 247, 519 
amount of, 520 
appearance of, 520 
chemical composition of, 521 
microscopic examination of, 521 
reaction of, 522 
specific gravity of, 521 
Cestodes, 217 
Chalicosis, 275 
Charcot-Levden crystals, in the feces, 196, 

216 
Charcot-Levden crystals in the nasal dis- 
charge, 248 
in the sputum, 257, 269 
Chemical examination of the blood, 24 
of the buccal secretion, 122 
of cystic fluids, 516 
of the feces, 142, 199 
of the gastric juice, 139 
of the milk, 538 
of the pus, 512 
of the semen, 525 
of the sputum, 270 
of transudates, 509 
of the urine, 293 
Cenomonadina, 217 
Chenzinsky-Plehn's stain, 87 
Chlorides in the urine, 295 
estimation of, 298 

according to Neubauer and 
Salkowski, 303 
Salkowski and Volhard, 
298 
direct method, 302 
test for, 298 _ 
Chloroform-benzol mixture, 19 
Cholaemia, 53 
Cholera Asiatica, 245 

bacillus of, 236 
infantum, 244 
nostras, 243 

bacillus of, 236 
Cholesterin in the blood, 27 
in the feces, 204 
in the sputum, 269 
in the urine, 437 
test for, 205 



Choluria, 436 
Chorion villi, 534 
Chromogens in the urine, 425 
Chyluria, 120, 231, 386, 437, 455, 476 
Chymosin, 160 

estimation of, 162 
test for, 162 
Chymosinogen, 160 
estimation of, 162 
test for, 162 
Ciliated epithelium in cysts, 516 

in the sputum, 258 
Cladothrix, 268 
Coating of the tongue, 128 
Coccidia in the feces, 217 
Coffein, 346 

Coffin-lid crystals, 467, 477 
Colica mucosa, 211 

Colloid concretions in ovarian cysts, 517 
Colostrum, 535 
Comma bacillus, 236 
Concretions, biliary, 212 
fecal, 213 
intestinal, 213 
pulmonary, 257 
Congo-red test, for free acids, 147 
Conjugate sulphates, 313, 446 
Constipation, 206 
Copper test for uric acid, 352 
Coproliths, 213 
Corpora amylacea, 526 
Cresol in the feces, 201 

in the urine, 446 
Crystals of bilirubin, 475 

calcium carbonate, 477 
oxalate, 465 
phosphate, 467, 468, 476 

477 
sulphate, 469 
Charcot-Leyden, 196, 216, 248 

257, 269 
cholesterin, 27, 204, 269, 437 
cvstin, 320, 469 
fatty acids, 196, 216 
hsematoidin, 42, 269, 475 
ha?min, 40 
hippuric acid, 468 
indigo, 477 
leucin, 471 

magnesium phosphate, 468, 476 
phenyl-glucosazon, 412 
phosphate of spermin, 525 
Teichmann, 40 
triple phosphate, 467, 477 
tyrosin, 471 

urate of ammonium, 476 
uric acid, 463 
janthin, 473 
Curschmann' s spirals, 255 
Cylinders, mucous, 211, 243, 494 

urinary, 488 
Cylindroids, 488, 494 



INDEX. 



547 



Cylindruria, 488 
Cystein, 320 

Cysticercus cellulosa?, 226 
Cystin, 320, 469 
Cystinuria, 320, 458, 469 
Cysts, colloid, 517 

contents of, 516 

dermoid, 517 

fibro-cystic, 517 

hydatid, 518 

ovarian, 516 

pancreatic, 518 

parovarian, 517 

DA LAND'S hsematokrit, 99 
Decidual cells, 534 
^-granulations of Ehrlich, 69 
Denaturization, 162 
Dennige's test, for acetone, 54, 450 
Dermoid cysts, 517 
Deutero-albumoses, 163 
Dextrin in the urine, 423 
Dextrose in the urine (see Glucose) 
Diabetes, 407 

alternans, 350 

blood test in, Bremer' s, 59 

Williamson's, 48 
elimination of sugar in, 407 

of urea in, 327, 409 
hepatogenic, 408 
Hirschfeld'sformof, 327, 409 
insipidus, 282, 298 
myogenic, 408 
phosphatic, 306 
Diacetic acid in the urine, 452 

tests for, 452 
Diaceturia, 452 
Diamins in the feces, 242 
urine, 320, 457 
Diarrhoea, 206 
Diathesis, oxalic acid, 370 

uric acid, 349 
Diazo-reaction (see Ehrlich' s reaction), 

443 
Digestion, gastric, 162 
of albumins, 162 

albuminoids, 164 
carbohydrates, 164 
milk, 164 

native albumins, 162 
products of, 162 
Dimethyl-amido-azo-benzol test, 148 
Diphtheria, 129 
Diplococcus meningitidis intracellularis, 

523 
Diplococcus pneumonia?, 104, 125, 266 
Distoma, Buskii, 230 
capense, 121 
conjunotum, 231 
haematobium, 231, 506 
hepaticum, 229 
heterophyes, 231 



Distoma lanceolatum, 229 

pulmonale, 231, 262 

rhatonisi, 230 

sibiricum, 230 

spatulatum, 230 
Distomiasis, 121 
Donne's pus-test, 482 
Drosophila melanogastra, 217 
Drugs, effect of, on the color of the stools, 

193 
Drysdale's corpuscles, 577 
Dysentery, 244 

amoebic, 244 

tropical, 244 

EAKTHY phosphates, 312 
Eberth's bacillus, 100, 237 
Echinococcus, 257, 258, 261 

membranes in the sputum, 257 
f-granulations of Ehrlich, 67 
Ehrlich' s granulations, 65 
hsematoxylin-eosin, 87 
neutral stain, 88 
reaction, 443 
staining methods, 86 
tri-glycerin mixture, 87 
-acid stain, 86 
Einhorn' s bucket, 136 

saccharimeter, 411 
Elastic tissue in the sputum, 253, 260 
Eisner's method, 238 
Emerald-green test for hydrochloric acid, 

150 
Enteritis, acute, 242 
chronic, 243 
membranous, 211, 243 
mucous (see Membranous), 211, 243 
Enterogenic peptonuria, 384 
Enteroliths, 213 
Eosin, staining with, 88 

-methylal, 88 
Eosinophilia, 78 

Eosinophilic leucocvtes in the blood, 
68 
in the sputum, 257 
Epithelial cells, alveolar, 259 
ciliated, 258 

in the buccal secretion, 124 
in the gastric contents, 185 
in the tocos, 195 
in the sputum, 258 
in the urine, 478 
in the vaginal secretions, 529 
Eructatio nervosa, 179 
Erythrodextrin, 165 

test for, 1(^7 
Esbach's albuminimeter, 395 

method of estimating albumin, 395 
reagent, W<> 
Ethyl-sulphide, 320 
Euchlorhydria, 146 
Eustroneylus srisras, 506 



548 



INDEX. 



Ewald's modification of Mohr's test for 

hydrochloric acid, 150 
Extractives in the blood, 27 
Exudates, 507, 510 

albumin in, 509 

chyloid, 515 

chylous, 515 

coagulation of, 510 

hemorrhagic, 510 

in cancer, 510 

purulent (see Pus), 511 

putrid, 511 

serous, 510 

specific gravity of, 510 

in tuberculosis, 510 

FAT in the blood, 27, 52 
in the milk, estimation of, 540 
in the urine, 454, 475 
Fatty acids in the blood, 52 

estimation of, 177 

in the feces, 203 

in the gastric contents, 175 

in the pus, 512 

in the sputum, 270 

in the urine, 454 

mode of formation of, 175 

tests for, 176, 203 
casts, 492 
Febrile acetonuria, 449 
albuminuria, 376 
urobilin, 206, 425 
Fecal matter in the urine, 506 

vomiting, 184 
Feces, 192 

alimentary detritus in, 193, 210 

amount of, 192, 207 

annelides in, 217 

biliary acids in, 205 

biliary concretions in, 212 

blood in, 208, 215 

chemistry of, 199, 241 

color of, 193, 208 

composition of, 199 

consistence of, 193, 207 

crystals in, 196, 216 

examination of normal, 192 

flagellata in, 219 

foreign bodies in, 194 

form of, 193, 207 

gases in, 200 

general characteristics of, 192 

indol in, 201 

insects in, 235 

macroscopic constituents of, 193, 210 

microscopic constituents of, 194, 213 

number of stools, 192, 206 

odor of, 193, 207 

parasites in, 197 

animal, 216 

vegetable, 197, 235 
pathology of, 206 



Feces, phenol in, 201 

protozoa in, 217 

reaction of, 199, 208 

skatol in, 201 

technique in examination of, 192 

trematodes in, 217 

vermes in, 217 
Fehling's solution, 410 

test for sugar, 410 
Ferment, milk-curdling, 160 

of saliva, 123 
Fermentation -test for sugar, 411 
Ferments in the gastric juice, 157 
Ferrometer, Jolle's, 34 
Feser's lactoscope, 540 
Fibrin, 25 

estimation of, 45 

ferment, 25 

in the blood, 25 
urine, 386 

test for, 401 
Fibrinogen, 25 
Fibrinoglobulin, 25 
Fibrinoses, 164 
Fibrinous casts, 254 

coagula in the sputum, 254 

in the urine (see Chyluria) 
Filaria Bancrofti, 119 

diurna, 119 

Mansoni, 119 

nocturna, 119 

sanguinis hominis, 119 

Wuchereri, 119 
Filariasis, 119 
Finkler-Prior bacillus, 236 
Flagellata, 219 
Fleischl's hsemometer, 37 
Florence's test for semen, 527 
Forceps, cover-glass, 84 
Foreign bodies in the feces, 194 

in the sputum, 257 
urine, 506 
Formic acid, detection of, 203 
Freund's method of determining acidity 
of urine, 292 

pneumococcus, 105, 267 
Friedliinder's bacillus, 106 
Furfurol test for bile acids, 206 
Futcher's malarial stain, 111 

GABBETT'S staining method, 265 
Galakturia, 455 
Gallstones in the feces, 212 

analysis of, 213 
Gangrene of the lung, 272 
Garrod' s test for uric acid in the blood, 
51 
test for homogentisinic acid, 442 
Gases in the blood, 27 
in the feces, 200 
in the gastric contents, 178 
in the urine, 456 



INDEX. 



549 



Gastric contents, examination of, 132 
(see also Gastric Juice) 
juice, 132 

acetic acid in, 176 

acetone in, 180 

acidity of, 139 

amount of, 138 

antiseptic properties of, 144 

aspiration of, 136 

butyric acid in, 176 

cause of acidity of, 139 

chemical composition of, 139 

examination of, 139 
chymosin in, 160 
chymosinogen in, 160 
expression of, 136 
fatty acids in, 175 
ferments in, 157 
free acids in, 139 
gases in, 178 

general characteristics of, 137 
hydrochloric acid in, 139 
hyperacidity of, 143 
hypersecretion of, 138, 143 
indirect examination of, 189 
lactic acid in, 168 
method of determining the total 

acidity of, 141 
methods of obtaining, 134 
microscopic examination of, 185 
milk-curdling ferment of, 160 
organic acids in, 177 
pepsin in, 157 
pepsinogen in, 157 
proteids in, 162 
ptoma'ins and toxalbumins in, 

180 
secretion of, 132 
zymogens in, 157 
digestion, products of, 162 
of albuminoids, 164 
carbohydrates, 164 
native albumins, 162 
analysis of products of, 166 
Gastrosucorrhcea mucosa, 182 
Gigantoblasts (see Megaloblasts), 62 
Glanders, bacillus of, 108 
Globulinoses, 164 
Glucose, 402 

Bottger's test for, 410 
Cause's method, 416 
Differential density method of esti- 
mating, in the urine, 417 
Einhorn's method, 418 
Fehling's method, 414 

test for, 410 
Fermentation test, 411 
in the blood, 27, 46 

estimation of, 47 
Knapp's method, 117 
Lohnstein's method, 418 
Ny lander's test, 410 



Glucose, phenyl-hydrazin test, 412 

polarimetric method, 412, 419 

quantitative estimation of, 414 

tests for, 409 

Trommer's test for, 409 
Glycogen in the blood, 48 

in the sputum, 271 

test for, 49 
Glycosuria, 402 

digestive 402 

e saccharo, 405 

ex amylo, 405 

persistent, 407 

transitory, 406 
Glycosuric acid, 441 
Glycuronic acid in the urine, 424 
Gmelin's reaction, 437 
Gonococcus in the blood, 106 

in the mouth, 127 

in urethral discharge, 502 

of Neisser, 502 

staining of, 503 
Gonorrheal stomatitis, 127 

threads in the urine, 503 
Gowers' hsemoglobinometer, 33 
Gram's method of staining, 130 
Granular degeneration, 61 
y-granulation of Ehrlich, 69 
Grape sugar (see Glucose) 
Gregarina, 223 

Grethe' s method of staining tubercle ba- 
cilli in the urine, 502 
Guaiacum test for blood, 401 
Guanin in the urine, 346, 359 
Gum, animal, 424 
Gunning' s mixture, 342 
Giinzburg' s packages, 189 

reagent, 149 
Gynaecophorus, 121 

H^MATEMESIS, 183 
Hsematin, 40, 434 
Hsematinuria, 385, 434 
Hpematoblasts, 91 
Hamiatoidin in the blood, 42 
in the sputum, 269 
in the urine, 475 
Hsematokrit, 99 
Haematoporphyrin in the blood, 43 

in the urine, 434 
Hsematoporphyrinuria, 43, 434 
Hematuria, 386, 485 
Hsemin (see Teichmann's crystals), 40 
Hsemocytometer of Thoma-Zeiss, 92 
Haemoglobin, 17. 28 
carbon dioxide, 40 
monoxide, 39 
estimation o\\ with Fleischl's hanno- 
meter, 31 
with Gowers' hsemoglobinome- 
ter, 33 
nitric oxide, 39 



550 



INDEX. 



Haemoglobin, sulphuretted hydrogen, 39 

tests for, 400 
Hsemoglobinsemia, 38, 42, 385 
Haemoglobinometer of Gowers, 33 
Hemoglobinuria, 42, 385 
Hsemokonia, 92 
Haemometer of Fleischl, 31 
Hemospermia, 527 
Halitus sanguinis, 18 
Hammerschlag' s method, 19 
Haycraft's method of estimating uric acid, 

355 
Hay em's fluid, 93 
Heart disease, cells of, 274 

sputum in, 274 
Hehner-Seemann' s method of estimating 

organic acids, 177 
Heintze's method of estimating uric acid, 

358 
Heller' s test for albumin, 388 

for blood, 401 
Hepatogenic icterus, 436 
Heteroalbumoses, 163 
Heteroxanthin in the urine, 347, 359 
Hexon bases, 163 
Hippuric acid in the urine, 361, 468 

estimation of, 363 

properties of, 362 

test for, 363 
Histidin, 163 
Histon in the urine, 388 

test for, 401 
Hoffmann's test for tyrosin, 473 
Hofmeister's method of estimating hip- 
puric acid, 364 

test for leucin, 473 
Homialomyia. 217 
Homogentisinic acid, 441 
Hopkins' method of estimating uric acid, 

353 
Hiifner's apparatus for the estimation of 

urea, 339 
Huppert's test for bile-pigment, 437 
Hydatid cysts, 518 

echinococcus membranes and booklets 
in, 518 

sodium chloride in, 518 

succinic acid in, 518 
Hydrobilirubin, 206 
Hydrocele fluid, 509 

cholesterin in, 509 
Hydrochinon in the urine, 440 
Hydrochloric acid in the gastric juice, 
139 

estimation of, according to Leo, 
156 
Martius and Liittke, 154 
Topfer, 152 

amount of, 146 

combined, 151 

free, 146 ^ 

quantitative estimation of, 152 



Hydrochloric acid, significance of, 144 

source of, 143 

tests for, 148 
Hydrocyanic acid poisoning, blood 

changes in, 40 
Hydronephrosis, 518 
Hydrothionuria, 456 
Hypalbuminosis, 45 
Hyperalbuminosis, 45 
Hyperchlorhydria, 147 
Hyperinosis, 45 
Hyperisotonia, 26 
Hyperleucocytosis, 72 

mixed, 80 

passive, 82 

pathologic, 75 

physiologic, 73 

polynuclear, eosinophilic, 78 
neutrophilic, 72 
Hypersecretio acida et continua, 143 
Hypersecretion, 138 
Hypinosis, 45 
Hypobromite solution, 333 
Hypochlorhydria, 146 
Hypoleucocytosis, 72, 82 
Hypoxanthin in the urine, 346, 359 

TCTERUS, 436 

JL hematogenic, 436 

hepatogenic, 436 

neonatorum, 436 

urobilin, 438 
Idiopathic bacteriuria, 504 

oxaluria, 370 
Ilasvay's reagent, 123 
Indican in the urine, 427 

tests for, 429 
Indicanuria, 427 
Indigo-blue in the urine, 443, 456, 477 

-red in the urine, 433 
Indigosuria, 456, 477 
Indol in the feces, 201 
tests for, 202 
Indoxyl, 427 

sulphate (see Indican), 427 
Influenza, bacillus of, 108, 267 
Infusoria in the feces, 217 

in the pus, 514 

in the vaginal discharge, 530 
Inosit in the urine, 424 
Insects in the feces, 235 
Intermittent albuminuria, 373 
Intestinal catarrh, 242, 243 

concretions, 212 

putrefaction, 313, 427 

tuberculosis, 239 
Intestines, diseases of, 242 
Iodoform-test for 1 
Iodospermin, 527 
Iron test, 209 

in blood, 34 
Isotonia, 26 



INDEX. 



551 



JAFFE'S test for indican, 430 
Jaundice (see Icterus), 436 
Jenner's stain, 89, 111 
Jolles' ferrometer, 34 

KELLING'S test for lactic acid, 171 
Kjeldahl's method, 341 
Knapp' s method, 417 
Koplik's bacillus, 267 
Korczynski and Jaworski's test, 209 
Krabbea grandis, 229 
Kreatin, 364 

properties of, 365 
Kreatinin, 364 

estimation of, 367 

properties of, 365 

test for, 366 

-zinc chloride, 365 



LACTIC acid, 168 
bacillus of, 168 
clinical significance of, 168 
estimation of, 173, 175 
fermentation, 168 
in the blood, 53 
in the gastric contents, 168 
mode of formation, 169 
tests for, 170 
Boas', 172 
Killing's, 171 
Strauss', 171 
Uffel man's, 170 
in the urine, 453 
Lactodensimeter of Quevenne, 538 
Lactoscope of Feser, 540 
Lactose in the urine, 422 
Laiose in the urine, 423 
Landois' estimation of the alkalinity of 

the blood, 23 
Latent microbism, 100 
Laveran's organism, 110 
Laverania malarise, 116 
Lecithin in the blood, 27 
Legal' s test for acetone, 449 
Leiner's test for casein, 214 
Leo's method of estimating hydrochloric 

acid, 156 
Leprosy, bacillus of, 264 
Leptothrix buccalis, 124 

pulmonalis, 272 
Leube's test, 188 
Leucin, 324, 471 
Leucocytes, 63 

basophilic, 69 

differential enumeration, 96 
differentiation according to their be- 
havior toward anilin dyes, 65 
Ehrlich's granulations in, 65 
enumeration of, 95 
eosinophilic, 68 
estimation of the number of, 95 



Leucocytes, general differentiation of the 
various forms of, 64 

indirect enumeration of, 96 

in the blood, 63 

in the exudates, 512 

in the feces, 195, 216 

in the sputum, 257 

in the urine, 481 

irritation forms, 71 

large mononuclear, 66 

lymphocytes, 65 

Mastzellen, 69 

myelocytes, 70 

myelogenic, 70 

neutrophilic, 67 

oxyphilic, 68 

polymorpho-nuclear, 67 

polynuclear, 67 

pseudo-lymphocytes, 71 

small mononuclear, 65 

transition forms, 67 

variations in number of, 72 
Leucocytosis (see Hyperleucocytosis), 72 

active, 72 

digestive form of, 73 

passive, 72 
Leukaemia, lymphatic, 82 

myelogenous, 80 
Leukopenia, 82 
Levulose in the urine, 423 
Lieben' s test for acetone, 449 
Lientery, 210 
Lipacidaeinia, 52 
Lipaciduria, 454 
Lipsemia, 52 
Lipuria, 454, 475 
Liver abscess, 272 

acute yellow atrophy of, 324 

diseases of, feces in (see Acholic 
stools), 
urine in (see Bile-pigments). 
Lochia, 531 

alba, 531 

rubra, 531 
Lohnstein's saccharimeter, 418 
Loftier' s bacillus, 129 

methylene-blue solution. J 29 
Lowy's method of estimating the alka- 
linity of the blood, 23 
Ludwig-Salkowski's method of estimating 

uric acid, 356 
Lymphocytes, (^ 
Lymphocytosis, 82 
Lysin, 163 

MACROCYTILEM1A. 55 
Magnesia mixture, 309 

soaps of, in the mine, 171 
Magnesium phosphate, 468, 476 
Malaria, plasm odium o\\ 110 
Maltose, L65, 423 
Mammary secretion, 585 



552 



INDEX. 



Marrow cells, 70 

Marsh gas in the gastric contents, 178 
Martius' and Liittke's method of esti- 
mating hydrochloric acid, 154 
Mason's lung (see Siderosis), 275 
Mastzellen, 69 
Meconium, 246 
Medico-legal test for blood, 40 
Megaloblasts, 62 
Megalocytes, 55 
Megastoma entericum, 223 
Melansemia, 119, 440 
Melanin in the urine, 439 

tests for, 440 
Melanogen, 439 

Membranous dysmenorrhoea, vaginal dis- 
charge in, 532 
Meningeal fluid, examination of, 519 
Menstruation, vaginal discharge in, 531 
Metalbumin in ovarian cysts, 526 
Methsemoglobin, 42 
Methemoglobinemia, 38, 42 
Methane (see Marsh Gas), 178 
Methyl-violet test, 150 
Michaelis' stain, 90 
Microblasts, 63 
Micrococci in pus, 514 
Micrococcus gonorrhceicus, 502 

urea?, 500 
Microcythsemia, 55 
Micro-organisms in the feces, 197 
in the milk, 537 
mouth, 124 
nasal secretion, 247 
pus, 514 
urine, 500 

vaginal discharge, 529 
Microscopic examination of the blood, 
55 
of the buccal secretion, 124 
of cystic fluids, 576 
of exudates, 572 
of the feces, 213 
of the gastric contents, 185 
of the nasal secretion, 217 
of the sputum, 257 
of transudates, 510 
of the urine, 460 
of the vaginal secretion, 529 
of the vomit, 185 
Milk, 535 

chemical composition of, 536 

cow's, 537 

-curdling ferment in the gastric juice, 

160 
in disease, 537 
examination of, 538 
fat in, estimation of, 540 
human, 536 
proteids of, 537 

secretion of, in the adult female, 536 
in the newly born, 535 



Milk, specific gravity of, 536, 538 

witches', 535 
Millon's reagent, 398 
Mohr's test for hydrochloric acid, 150 
Monadina, in feces, 219 
Monera, in the feces, 217 
Monocalcium phosphates, 468 
Motor-power of the stomach, examination 
of, 188 

Leube's method, 188 
Motor-power, salol test of Ewald and 

Sievers, 188 
Mouth, actinomycosis of, 128 

secretions of, 122 

tuberculosis of, 128 
Mucin, in the feces, 241 

in the urine, 387 
test for, 400 
Mucous corpuscles in the urine, 277 

cylinders in the feces, 211, 243 
in the urine, 494 
Mucus, in the gastric contents, 182 

in the feces, 211, 215 
Miiller- Weber test for blood, 183 
Murexid test, 352 
Myelin granules in the sputum, 259 
Myelocytes, eosinophilic, 71 

neutrophilic, 70 
Myosin oses, 164 

VfASAL catarrh, 247 
i\ secretion, 247 

cerebro-spinal fluid in, 247 

characteristics of, 247 

Charcot - Ley den crystals in, 

248 
in disease, 247 
Neisser, gonococcus of, 502 
Nematodes, 217 
Nessler's reagent, 172 
Neuridin, 320 
Neusser's granules, 69 

stain, 89 
Neutral phosphate of calcium, in the 

urine, 468 
Neutrophilic granules in the blood, 67 
Nitric acid test for albumin, 388 
Nitrites in the saliva, 123 
Nitrogen in the urine, 322 
estimation of, 341 

according to Kjeldahl, 347 
Will -Varrentrapp, 343 
Nitrogenous equilibrium, 325 
Nitro-prusside of sodium, as a test for 

acetone (see Legal' s test), 449 
Normal urobilin, 206, 425 
Normoblasts, 61 
Nose, secretion from, 247 
Nubecula in the urine, 277 
Nucleated red corpuscles, 61 
Nucleo-albumin, in the blood, 46 
in the urine, 387 



INDEX. 



553 



Nucleo-albumin, test for, 400 
Nylander's test for sugar, 410 

OBERMEYER'S reagent, 429 
(Edema of the lungs, sputum in, 274 
Oidium albicans, 268 
Olefiant gas, 179 
Oligochromemia, 30 
Oligocythemia, 30 
Oliguria, 283 
Organic acids in the blood, 52 

in the gastric juice, 177 

in the sputum, 270 

quantitative estimation of, 177 
Organized sediments of the urine, 478 
Ott'stest, 400 
Ovarian cysts, 516 

Oxalate of calcium crystals in the sputum, 
270 
in the urine, 465 
Oxalic acid in the urine, 369 

diathesis, 370 

properties of, 370 

quantitative estimation of, 371 

tests for, 371 
Oxaluria idiopathica, 370 
Oxaluric acid, 369 
Oxybutyric acid-/?, in the urine, 453 
Oxyhemoglobin, 18, 28 
Oxyuris vermicularis, 232 
Ozena, 247 

PACINI'S fluid, 93 
Pancreatic cysts, 518 

trypsin in, 518 
juice in the gastric contents, 183 
Pappenheim's method, 265 
Paracasein, 164 
Paracresol in the urine, 446 
Paramoecium coli, 223 
Parasites in the blood, 100 

in the feces, 216 

in the gastric contents, 184 

in the urine, 500 

malarial, 110 
Parasitology of the blood, 100 

of the sputum, 261 
Paraxanthin in the urine, 347, 359 
Patein's albumin, 383 
test for, 394 
Pathologic albuminuria, 372 

acetonuria, 448 

glycosuria, 407 

urobilin, 425, 438 
Pentoses in the urine, 423 

tests for, 423 
Pepsin in the gastric juice, 157 

estimation of, 160 

tests for, 159 
Pepsinogen in the gastric juice, 157 

estimation of, 160 

tests for, 160 



Peptones in the blood, 46 

in the feces, 241 

in the gastric contents, 163 

in the urine, 383 

tests for, 398 
Peptonuria, 383 

enterogenic, 384 

hematogenic, 384 

hepatogenic, 384 

histogenic, 384 

myelopathic, 384 

pyogenic, 384 

renal, 384 

vesical, 384 
Persistent glycosuria, 407 
Pettenkofer's test, 206 
Phagocytes, 63 
Phagocytosis, 64, 119 
Pharyngomycosis leptothrica, 129 
Phenol, 201, 440, 446 

estimation of, 447 

in the feces, 201 

in the urine, 440, 446 

tests for, 202, 447 
Phenylglucosazon, 412 
Phenylhydrazin hydrochloride, 412 
Phloroglucin test for pentoses, 423 

-vanillin test for hydrochloric acid, 
149 
Phosphates in the urine, 304, 468, 476 

estimation of, 310 

removal of, from urine, 312 

separate estimation of alkaline and 
earthy, 312 

tests for, 308 
Phosphatic sediments in the urine, 468, 

476 
Phthisis pulmonalis, sputum in, 273 
Physiologic acetonuria, 448 

albuminuria, 372 

glycosuria, 402 
Picric-acid test for albumin, 394 
Pigments in the feces, 206 

in the urine, 425 
Piorkowski' s method, 237 
Piria's test for tyrosin, 473 
Placenta sanguinis, 24 
Plaques, 91 

enumeration of, 98 
Plasma of the blood, 17, 24 
Plasmodium malaria 1 , 110 

crescentic bodies, 116 
flagellate bodies, 117 
hyaline bodies, 112 
ovoid bodies, 116 
pigmented extra-cellular bodies. 
117 
intra-cellular bodies, 113 
segmenting bodies, 114 
spherical bodies, 1 16 
Plastic bronchitis. 272 
Platodes, 217 



554 



INDEX. 



Plehn's malarial stain, 112 
Pneumaturia, 456 
Pneumoconioses, 274 
Pneumonia, diplococcus of, 105 

sputum in, 273 
Poikilocytes, 56 
Poikilocytosis, 56 
Polarimeter, 420 

Polychromatophilic degeneration, 59 
Polycythemia, 57 
Polymastigina, 220 
Polyuria, 280 

epicritic form of, 280 
Preparation of cover-glasses, 83 
Propepsin, 158 
Prostatic fluid, 526 
Protagon, 260 
Proteids, formed in the stomach, 162 

of the blood, 45 

reactions of, 166 
Proteoses, 163 
Proteus vulgaris, 104, 240 
Protoalbumoses, 163 
Protozoa, 216 

in the blood, 110 

in the feces, 217 

in the pus, 514 

in the sputum, 261 

in the urine, 505 
Pseudo-casts, 488, 494 

-gonococci, 503 

-lymphocytes, 71 
Psorospermiasis, 223 
Ptomains in the feces, 242 

in the gastric contents, 180 

in the urine, 457 
Ptyalin, 123 

test for, 123 
Pulmonary diseases, sputum in, 271 

abscess, 272 

gangrene, 272 

cedema, 274 
Purin, 346 

bases, 346 
Purulent exudates, 511 
Pus, 511 

chemistry of, 512 

crystals in, 514 

detritus in, 513 

general characteristics of, 511 

giant-corpuscles in, 513 

in the feces, 209 

in the gastric contents, 184 

in the urine, 482 

leucocytes in, 512 

microscopic examination of, 512 

parasites in, 514 

red corpuscles in, 514 

tests for, 482 
Putrescin, 242 ; 320, 457 
Putrid bronchitis, 272 

exudates, 511 



Pycnometer, 288 
Pyogenic peptonuria, 384 
Pyrocatechin in the urine, 440, 448 
Pyrocatechuic acid, 441 
Pyuria, 482 



Q 



UEVENNE'Slactodensimeter, 538 



REACH'S test, 190 
Reaction of the blood, 20 
of the feces, 199, 208 
of the gastric juice, 139 
of the urine, 288 
Eed blood-corpuscles, 17, 53 

behavior toward anilin dyes, 58 
degeneration of, 59, 61 
enumeration of, 92 
nucleated forms, 61 
variations in color, 58 
variations in form, 56 
variations in number, 56 
variations in size, 55 
Relapsing fever, spirillum of, 109 
Renal albuminuria, 375, 382 
Resorcin test, 149 

Resorptive power of the stomach, ex- 
amination of, 189 
Reynolds' test for acetone, 450 
Rhizopoda, 217 
Rice-water stools, 245 
Rosenbach's reaction, 433 

test for bile-pigments, 437 
Round worms, 231 
Roy's method of determining the specific 

gravity of the blood, 18 
Rust-colored expectoration, 251 

O ACCHARIMETER of Einhorn, 411 
U of Lohnstein, 418 

ofSoleil-Ventzke,_420 
Saccharomyces cerevisiee (see Yeast) 
Saliva, 122 

chemistry of, 122 

general characteristics of, 122 

in the gastric contents, 182 

in special diseases of the mouth/ 126* 

microscopic examination of, 124 

nitrites in, 123 

pathologic alterations of, 126 

ptyalin in, 123 

test for nitrites, 123 
for ptyalin, 123 
for sulphocyanides, 122 
Salivary corpuscles in, 124 
Salivation, 126 
Salkowski' s test for albumoses, 398 

test for phenol, 447 
Salol test of Ewald and Sievers, 188 
Sanarelli' s bacillus icteroides, 110 
Saprin, 320 
Sarcina pulmonalis, 268 



INDEX. 



555 



Sarcina urinse, 504 

ventriculi, 186 
Scherer's test for leucin, 473 
Schistosoma, 121 
Schizomycetes in the feces, 197 
Schmaltz and Peiper's method of deter- 
mining the specific gravity of the blood, 
19 
Scybala, 207 

Secretions of the mouth, 122 
Sediments in the urine, 460 

ammonio-magnesium phosphate in, 
467, 477 

ammonium urate in, 476 

amorphous urates in, 465 

basic magnesium phosphate in, 468, 
476 

bilirubin in, 475 

brick-dust, 463 

calcium carbonate in, 477 
oxalate in, 465 
sulphate in, 469 

cystin in, 320, 469 

epithelial cells in, 478 

fat in, 475 

foreign bodies in, 506 

hsematoidin in, 475 

hippuric acid in, 468 

in acid urines, 463 

in alkaline urines, 476 

indigo in, 477 

leucin in, 471 

leucocytes in, 481 

mode of examination of, 462, 489 

monocalcium phosphate in, 468 

neutral calcium phosphate in, 468 

non-organized, 463 

organized, 478 

parasites in, 500 

red corpuscles in, 485 

soaps of lime and magnesium in, 474 

spermatozoa, 498 

tube-casts in, 488 

tumor-particles in, 506 

tyrosin in, 471 

urates in, 465 

uric acid in, 463 

xanthin in, 473 
Semen, 525 

chemistry of, 525 

general characteristics of, 525 

microscopic examination of, 526 

pathology of, 526 

recognition of, in stains, 527 

spermatic crystals in, 525 

spermatozoa in, 526 
Sepsis, organisms in the blood, 105 
Sero-purulent exudates, 510 
Serous exudates, 510 
Serum-albumin, in the blood, 25 
estimation of, 395 
in the urine, 372 



Serum-albumin, tests for, 388, 402 

-globulin, in the blood, 25 
estimation of, 397 
in the urine, 383 
m test for, 397 
Siderosis, 275 
Simon's iodine stain, 112 
Skatol in the feces, 201 

tests for, 202 ' 
Skatoxyl, 446 

sulphate, 446 
Smegma bacillus, 264 
Soaps of lime and magnesium in the urine, 

474 
Sodium chloride in hydatid fluid, 518 
Spectroscope, 43 
Spermatic crystals, 525 
Spermatocystitis, 499 
Spermatorrhoea, 499 
Spermatozoa in the semen, 526 

in the urine, 498 
Spermin, 525 
Spiegler's reagent, 394 
Spirals of Curschmann, 255 
Spirillum of relapsing fever, 109 
Spirochseta Obermeieri, 109 
Sporozoa, 223 
Sputum, 249 

amount of, 250 

bacteria in, 262 

blood in, 251, 258 

cheesy particles in, 253 

chemistry of, 270 

color of, 251 

concretions in, 257 

configuration of, 252 

consistence of, 250 

Curschmann' s spirals in, 255 

crudum, 252 

crystals in, 269 

echinococcus membranes in, 257, 261 

elastic tissue in, 253, 260 

fibrinous casts in, 254 

foreign bodies in, 257 

general characteristics of, 250 

globosum, 253 

heterogeneous, 252 

homogeneous, 252 

in various diseases, 271 

macroscopic constituents, 253 

microscopic examination of, 257 

nummular, 252 

odor of, 252 

parasites, animal, in, 261 
vegetable, in, 262 

specific gravity of, 252 

technique in the examination o\\ 249 
Staining of blood. 86 

of tubercle bacilli. 265 
Staphylococcus pyogenes albus, 106 
aureus, 106 
citreus. 106 



556 



INDEX. 



Starch, digestion of, 164 

solution, 174 
Steatorrhea, 210 
Stercobilin, 206, 438 
Stokes' fluid, 28 
Stomach, motor-power of, 188 
rate of absorption in, 189 
-tube, 134 

contraindications to its use, 135 
its introduction, 135 
washing, 137 
Stomatitis, catarrhal, 126 
gonorrheal, 127 
ulcerative, 126 
Stools ( see Feces ) 
Strauss' test for lactic acid, 171 
Streptococcus pyogenes, 106 
brevis, 106 
conglomeratus, 106 
longus, 106 
Strongyloides, 217 
Strongylus duodenalis, 232 
Stycosis, 275 

Succinic acid in hydatid fluid, 518 
Sudan stain for fat, 476 
Sugar in the blood, 27, 46 
in the urine, 402 
tests for, 409 
Sulphanilic acid test (see Ehrlich's reac- 
tion) 
Sulphates, estimation of, 317 
in the urine, 313, 446 
tests for, 316 
Sulphocyanides in the saliva, 122 

in the urine, 319 
Sulphur, neutral, in urine, 319 

estimation of, 321 
Sulphuretted hydrogen in the gastric con- 
tents, 179 
in the urine, 456 
tests for, 457 
Syntonin, 166 

T^NIA cucumerina, 227 
diminuta, 227 

echinococcus, 261 

flavapunctata, 227 

mediocanellata, 225 

nana, 226 

saginata, 225 

solium, 225 
Tartar, 127 

Tauro-carbaminic acid in urine 319 
Teichmann's crystals, 41 
Test-breakfast of Boas, 134 

of Ewald and Boas, 133 

-dinner of Riegel, 134 

-meal of Salzer, 134 

-meals, 133 
Thecosoma, 121 
Theobromin, 347 
Theophyllin, 347 



Thiosulphates in urine, 319 
Thoma-Zeiss' haemocytometer, 92 
Thrush, 127 
Toison' s fluid, 93 
Tollens' orcin test, 423 

phloroglucin test, 423 
Tongue, coating of, 128 
Tonsillitis, 129 
Tonsils, coating of, 129 
Toepfer's test for hydrochloric acid, 148 
Toxalbumins in the gastric contents, 180 
Transitory glycosuria, 406 
Transudates, 507 
albumin in, 508 
chemistry of, 509 
coagulation of, 509 
general characteristics of, 507 
microscopic examination of, 510 
specific gravity of, 507 
Trematodes, 229 
Trichina cystica, 119 

spiralis, 234 
Trichocephalus dispar, 233 
Trichomonas vaginalis, 222, 261, 505, 530 
Trichotrachelides, 233 
Triple-phosphate crystals in the sputum, 
270 
in the urine, 467, 477 
Tripperfaden, 503 
Trommer's test, 409 

Tropa?olin test for hydrochloric acid, 150 
Trypsin in pancreatic cvsts, 518 

test for, 5l8 
Tube-casts in the urine, 482 
amyloid, 493 

clinical significance of, 496 
compound hyaline, 490 
fatty, 492 
formation of, 494 
granular, 490 
hyaline, 489 

mode of examination of, 489 
pseudo-, 488, 494 
pus, 490 
staining of, 489 
true, 489 
waxy, 492 
Tubercle bacilli, detection of, 265 
in the blood, 107 
in the feces, 239 
in the milk, 538 
in the mouth, 128 
in the pus, 514 
in the sputum, 262 
in the urine, 502 
Tumor-particles in the gastric contents, 
187 
in the urine, 506 
Trypsin, 518 

Typhoid fever, bacillus of, 100, 237 
in the blood, 100 
in the feces, 237 



INDEX. 



557 



Typhoid fever, stools in, 245 
Tyrosin in the feces, 201 

in the sputum, 270 

in the urine, 324, 471 

tests for, 473 

UFFELM ANN'S test for lactic acid, 170 
Unorganized sediments in urines, 463 
Uraemia, 50 

Urates in urinary sediments, 465, 476 
Urea in the blood, 49 
in the urine, 322 

estimation of, 333 
properties of, 329 
separation of, 332 
tests for, 330 
-nitrate, 330 
-oxalate, 330 
Ureometers, 334 
Doremus', 339 
Green's, 339 
Hufner's, 339 
Marshall's, 339 
Simon's, 335 
Squibb' s, 341 
Urethritis, gonorrheal, 502 
Uric acid, 345 

crystals of, 463 
diathesis, 349 
estimation of, 49, 51, 353 
Folin' s method, 353 
Gravimetric method, 354 
Haycraft's method, 355 
Heintz's method, 358 
Hopkins' method, 353 
Ludwig - Salkowski's me- 
thod, 356 
in the blood, 50 
in the saliva, 122 
in the urine, 345, 463 
properties of, 351 
tests for, 352 
Urinary cylinders, 489 

sediments, 460 
Urine, 276 

acetone in, 448 
acidity of^ 292 
albumins in, 372 
alkapton in, 441 
alloxur bases in, 346 
animal parasites in, 503 
benzoic acid in, 363 
bile acids in, 437 

pigments in, 435 
blood in, 386, 485 
carbohydrates in, 402 
casts in, 489 
chemistry of, 293 
chlorides in, 295 
chromogens in, 425 
chyle in, 386, 437, 455, 476 
color of, 278 



Urine, consistence of, 279 

diacetic acid in, 452 

Ehrlich's reaction in, 443 

epithelium in, 478 

fat in, 454, 475 

fatty acids in, 454 

fecal matter in, 506 

foreign bodies in, 506 

gases in, 456 

general appearance of, 277 

chemical composition of, 293 

hippuric acid in, 361 

indican in, 427 

kreatin in, 364 

kreatinin in, 364 

lactic acid in, 453 

leucocytes in, 481 

microscopic examination of, 460 

mineral ash, estimation of, 294 

neutral sulphur in, 319 

nitrogen in, 322, 341 

nubecula in, 277 

odor of, 279 

organized sediments in, 478 

oxalic acid in, 369 

oxaluric acid in, 369 

oxybutyric acid in, 453 

parasites in, 500 

phenol in, 440, 446 

phosphates in, 304 

pigments in, 425 

ptomai'ns, 457 

pus in, 482 

pyrocatechin in, 440, 448 

quantity of, 280 

reaction of, 288 

sediments in, 277, 460 

solids in, 287 

specific gravity of, 283 

spermatozoa in, 498 

sugar in, 402 

sulphates in, 313, 446 

urea in, 322 

uric acid in, 345, 463 

vegetable parasites in, 500 

xanthin bases in, 346, 359 
Urines, blue, 443 

green, 443 
Urinometer, 286 
Urobilin, febrile, 206, 425 

normal, 206, 425 

pathologic, 425, 438 

tests for, 439 

Bang's test, 400 
Gerhardtf s, 439 
v. Jaksch's, 439 
Urobilinogen, 438 
CJrobilinuria, 138 
Urochrome, 425 
Uroerythrin, 426 
Urofascohsematin, 131 
(Jroheematin. 432 



558 



INDEX. 



Urohaematoporphyrin, 434 
Uroleucinic acid, 441 
Urophain, 433 
Urorosein, 433 
Uroroseinogen, 433 
Urorubrohaematin, 434 
Uroxanthinic acid, 441 
Urrhodinic acid, 441 

VAGINAL blennorrhea, 530 
discharge, 529 

bacteria in, 529 

during menstruation, 531 

following parturition, 531 

general description of, 529 

in abortion, 534 

in gonorrhoea, 534 

in membranous dysmenorrhea, 

532 m 
in uterine cancer, 534 
in vaginitis, 532 
in vulvitis, 532 
parasites in, 529, 530 
reaction of, 529 
Vaginitis exfoliativa, 532 
Valeur globulaire, 33 
Vermes, in the blood, 119 
in the feces, 224 
in the sputum, 261 
in the urine, 505 
Vitali's test for pus, 482 
Vitelloses, 163 
Vomited material, 181 
bile in, 183 
blood in, 183 
food material in, 181 
mucus in, 182 
odor of, 185 



Vomited material, pancreatic juice in, 183 

parasites in, 184 

pus in, 184 

saliva in, 182 

stercoraceous material in, 184 
Vomitus matutinus, 182 
v. Fleischl' s heemometer, 31 

WANG' S estimation of indican, 430 
Wassiliew's estimation of albumin, 
395 

Waxy casts, 492 

Weigert-Ehrlich stain, 265 

Weyl's test for kreatinin, 366 

Whetstone crystals (see Uric acid), 463 

White blood-corpuscles (see Leucocytes), 
63 

"Whooping-cough, sputum in, 267 

Worms (see Vermes), 224 

Widal's serum-test, 100 

Williamson's blood-test, 48 

Will-Varrentrapp's method of estimat- 
ing nitrogen, 343 

Woodward's method of estimating milk- 
proteids, 540 

y AXTHIX bases in the blood, 52 
-A. in the urine, 346, 359, 473 

estimation of, 360 
Xantho-proteic reaction, 202 

YEAST-CELLS in the gastric contents, 
185 
in the urine, 504 

ZIEHL-NEELSEN stain, 266 
Zymogens in the gastric juice, 157 



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